Widespread QAA Program Failures and Multiple Care Deficiencies
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) program failed to identify and address multiple care issues affecting all 84 residents, as evidenced by observations, record reviews, and interviews. Specific deficiencies included a resident not receiving dignified dining service, lack of gradual dose reduction for a resident on psychotropic medication, failure to provide bed hold policy and ombudsman notification for two residents, and failure to revise care plans for residents with supplemental oxygen and an immobilizer brace. Additional issues included failure to prevent and manage skin breakdown, provide foot care, follow transfer protocols resulting in a knee fracture, and implement nutritional interventions for a resident with significant weight loss. There were also failures in communication regarding wound care, provision of annual in-service training for CNAs, and follow-up on a resident's request for new dentures. Further deficiencies were noted in pharmacy oversight, medication management, dental services, dietary management, kitchen sanitation, and infection control practices, including improper use of PPE and handling of soiled linens. The facility also lacked a Certified Dietary Manager and failed to maintain a sanitary kitchen environment. The QAA committee reportedly met monthly, but the ongoing issues indicated a lack of effective identification and resolution of care concerns, placing all residents at risk for unidentified and ongoing care issues.