Failure to Implement Corrective Actions for Systemic Quality Deficiencies
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) committees failed to implement corrective actions for several identified systemic problems. These deficiencies included the lack of systems to ensure timely response to call lights, proper implementation of activities of daily living, accurate pharmaceutical services and procedures, prevention of significant medication errors, correct storage and labeling of biologicals and medications, sanitary food storage, and maintenance of clinical records according to professional standards. The report notes that these failures had the potential to result in residents not receiving necessary services and care. Interviews with the Administrator and Director of Nursing (DON) confirmed ongoing issues in areas such as pressure ulcers, medication management, and call light response. The DON acknowledged that all staff are responsible for identifying skin issues and answering call lights, and recognized the need for improvement in the deficient practices identified. Review of the facility's QAPI policy indicated objectives for monitoring and correcting negative indicators, but the report documents that these objectives were not met in practice.