Failure to Implement Corrective Actions for Repeat Deficiencies
Penalty
Summary
The facility's Quality Assessment and Assurance Committee (QAA) failed to implement corrective actions from the previous re-certification survey, resulting in repeated deficiencies across multiple areas. These deficiencies included issues with nutrition and hydration, pain management, food procurement, sanitary food storage and preparation, QAPI/QAA improvement, reasonable accommodation of resident needs and preferences, development and implementation of comprehensive care plans, infection prevention and control, quality of care, pharmaceutical services, drug regimen review, and the labeling and storage of drugs. During interviews and record reviews, facility leadership, including the DON, Administrator, and QA nurse, acknowledged that these deficiencies had been identified previously and continued to fluctuate without consistent resolution. A review of QAPI reports on falls revealed that the facility set specific goals to reduce the number of repeated falls and falls occurring in the evening, but these goals were not consistently met over several months. The fall rates varied, with only one month meeting the targeted reduction, while other months failed to achieve the set objectives. The facility's QAPI policy outlined responsibilities for the committee, such as collecting and analyzing performance data, identifying and resolving negative outcomes, and utilizing root cause analysis, but the ongoing presence of repeat deficiencies indicated these processes were not effectively implemented.