Failure to Maintain Effective QAA Program and Address Multiple Quality Deficiencies
Penalty
Summary
The facility failed to maintain an effective Quality Assessment and Assurance (QAA) program, as evidenced by multiple deficiencies identified during the survey. Surveyors observed that the QAA committee did not adequately address or correct quality deficiencies prior to the survey, resulting in ongoing issues affecting resident care and safety. The facility's QAPI policy outlined a comprehensive, data-driven approach to quality improvement, but in practice, the facility did not implement or follow through with these processes, as shown by the repeated and varied deficiencies across multiple care areas. Specific deficiencies included failures in providing dignified care during meals, ensuring reasonable accommodation for residents' needs such as accessible call lights and safe wheelchair transport, and protecting the privacy and confidentiality of medical records. Additional issues were noted in the areas of nutrition and hydration, with improper positioning of residents during meals, and in the use of pressure-reducing devices for residents at risk of pressure ulcers. The facility also failed to apply necessary splints for residents with contractures and dysphagia, and did not secure hazardous materials or equipment, exposing cognitively impaired residents to immediate jeopardy. Environmental hazards, lack of effective fall interventions, and unsanitary storage of respiratory equipment were also documented. Further deficiencies were found in staff management and training, including the absence of required yearly performance evaluations and in-service education for Certified Nurse Aides, incomplete and inaccurate staffing data submission, and failure to maintain required nurse staffing records. The facility did not conduct a thorough facility-wide assessment to determine necessary resources for competent care, and failed to ensure person-centered activities for residents with dementia. Medication management was also deficient, with the consultant pharmacist and physicians not providing appropriate indications or risk-benefit analyses for antipsychotic medications. Dietary services were found lacking in sanitary standards, and infection control practices were not consistently followed, as evidenced by improper storage of oxygen tubing, CPAP masks, and unsanitary handling of equipment and supplies.