QAA Program Fails to Identify and Address Multiple Facility Deficiencies
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) program failed to identify and address multiple issues affecting 33 out of 44 residents. Deficiencies included failure to treat two residents with dignity, improper completion of beneficiary notices for three residents, and lack of physician orders, assessments, and updated care plans for a resident's use of a lap buddy. The facility did not provide documentation of a background check for a staff member prior to employment, failed to report a resident's fall with fracture and another resident's injury to the State Survey Agency, and did not provide required notifications or bed hold policies to residents or their representatives during transfers and discharges. Additionally, care plans were not revised for appropriate use of prophylactic antibiotics, and safety measures such as floor motion detectors and secure chemical storage were not consistently implemented. Further deficiencies included not ensuring a Registered Nurse was on duty for the required hours, failure to post nurse staffing information, and the pharmacy consultant not reporting the physician's rationale for continued antibiotic use. The facility also failed to ensure drugs and biologicals were not expired, did not employ sufficient staff with appropriate competencies in food and nutrition services, and did not maintain a clean and sanitary kitchen environment. Hospice services information was not integrated into care plans, and the medical director did not sign in on quarterly QAA meetings. Despite department heads being expected to bring concerns to QAA meetings and conducting mock surveys, the facility did not develop or implement effective plans of action to address these issues, as evidenced by the multiple deficiencies cited.