Failure to Implement Effective QAPI Action Plans for Wound Care, Infection Control, and Staffing
Penalty
Summary
The facility failed to ensure that its Quality Assurance Committee developed and implemented an effective Performance Improvement Plan (PIP) to address several critical areas, including pressure ulcer management, infection control surveillance, adequate nursing staffing, and annual wound care competencies. Record review revealed that quarterly QAPI meetings were held, but the meeting summaries did not include specific action plans for implementing wound consultant recommendations, infection control surveillance (including antibiotic stewardship and line listing), ensuring sufficient and qualified nursing staff, or verifying that nursing staff had completed annual wound care competencies. Sign-in sheets for QAPI meetings also showed that key interdisciplinary team members, such as the Assistant Director of Nurses, Staff Development Coordinator, and Infection Preventionist, were not present or did not sign in for multiple meetings. Interviews with facility leadership confirmed these deficiencies. The Director of Nurses (DON), who started in April 2025, acknowledged awareness of wound care concerns and identified a culture where nurses did not add wound consultant recommendations to physician orders, which led to the deterioration of a wound for a resident. The DON stated that no PIPs addressing wound recommendations, infection control surveillance, staffing, or annual wound competencies had been initiated prior to her start date. She indicated that systemic issues were expected to be identified by the interdisciplinary team and brought to QAPI for action planning, but this process was not followed. The Administrator, who began in August 2024, reported managing three quarterly QAPI meetings but did not initiate PIPs for the specific issues identified, including wound care, staffing, infection control surveillance, and annual wound competencies. He attributed this to a lack of awareness of these specific concerns and noted that the DON did not inform him of the issues. The Administrator also confirmed that there was a period without a permanent Infection Preventionist, Staff Development Coordinator, or Assistant Director of Nurses, and that he was unaware of the absence of an infection control surveillance plan and incomplete staff wound care competencies. These failures resulted in the facility not addressing or correcting systemic quality deficiencies.