Deficient Administrative Oversight in Staff Training, Infection Control, and QAPI
Penalty
Summary
The facility failed to provide appropriate administrative oversight to ensure effective use of resources and to attain the highest practicable well-being of each resident. Specifically, the administration did not ensure that pre-employment health requirements and dementia training were provided to all staff, as evidenced by 3 out of 5 new hire employee records lacking proof of dementia training. Additionally, there was a lack of orientation and education for staff on policies and procedures related to dementia care. The administration also failed to implement and maintain an Infection Prevention and Control Program (IPCP), including the absence of an Antibiotic Stewardship Program for monitoring, tracking, and improving antibiotic use and infection control measures. Interviews revealed that the Administrator was unaware of the missing dementia training documentation and could not provide evidence that clinical concerns, such as infection control and antibiotic stewardship, were discussed in QAPI meetings. The Medical Director confirmed the absence of an Infection Control Program and stated that infection monitoring, data collection, and reporting were not in place. Furthermore, the President of Operations was not informed about the lack of QAPI activities for several months and did not review QAPI minutes to ensure compliance. These failures resulted in deficiencies cited under F837, F880, and F881.