Failure to Implement Comprehensive QAPI Program and Staff Education
Penalty
Summary
The facility failed to develop, implement, and maintain a comprehensive Quality Assurance and Performance Improvement (QAPI) program that addressed the full range of care and services, as required by its own policy. The QAPI program was not comprehensive or data-driven, and did not focus on indicators of outcomes related to quality of life, quality of care, and services to residents. The facility only developed QAPI plans related to staff education and infection control after these issues were identified by the Administrator, rather than proactively through a systematic process. Interviews revealed that the Director of Nursing (DON), who had only recently started, was not maintaining infection tracking line listings and could not locate any previous records. There was also no documentation available for the facility's Antibiotic Stewardship Program, and the DON confirmed that no one was currently overseeing this program. A review of employee records showed significant gaps in required dementia training and annual education, with most employees lacking the necessary training hours and annual competency reviews. The Administrator and Medical Director both stated expectations for infection surveillance and antibiotic stewardship, but these were not being met in practice. The Administrator acknowledged that QAPI meetings were held monthly, but projects did not address infection control or staff education, despite being aware of deficiencies in these areas. The lack of follow-up and failure to incorporate these issues into the QAPI program contributed to the deficiency.