Repeated Deficiencies in Infection Control and Medication Management
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA)/QAPI committee failed to demonstrate an effective plan of action to correct previously identified quality deficiencies, as evidenced by repeated citations for F880-Infection Prevention and Control and F761-Label/Store Drugs and Biologicals. During a recertification survey, surveyors observed ongoing issues such as trash and food left on the floor in a resident pantry, an indwelling catheter tube touching the floor, staff not wearing proper personal protective equipment (PPE), and improper hand hygiene during wound care. Additionally, an unattended and unlocked medication cart was found, and medication, a glucometer, and lancets were left at a resident's bedside. The facility's QAPI plan outlines a multidisciplinary committee and a systematic approach to monitoring and improving care, but the repeated deficiencies indicate that these processes were not effectively implemented or sustained. At the time of the survey, there were 91 residents in the facility. The QAPI committee, which includes the DON, department heads, administrator, wound care nurse, dietary staff, and medical director, meets monthly to review quality initiatives and audit outcomes, but the cited deficiencies persisted in the areas of infection control and medication management.