QAPI Committee Failed to Identify and Address Multiple Quality Issues
Penalty
Summary
The facility's QAPI committee failed to identify, address, and implement appropriate plans of action for several critical areas, including call light response times, grievance handling, timely and accurate MDS submissions, antibiotic stewardship, infection control, maintenance of complete and accurate medical records, annual review and updating of policies and procedures, and monitoring nursing staff compliance with standards of practice. Interviews and record reviews revealed that concerns raised by residents and documented in council minutes regarding call light response were not followed up with ad hoc meetings or effective action. Grievances from resident council meetings were not consistently documented or brought to the interdisciplinary team, and the process for addressing and tracking grievances was incomplete. The facility also failed to address late and incorrect MDS submissions, and the NHA acknowledged ongoing issues with documentation and coding accuracy. Antibiotic stewardship and infection control practices were not aligned with facility policy, and the Infection Control Preventionist had not compared the Infection Control Pathway to policy. Medical records were found to be incomplete and disorganized, with ongoing issues in documentation by CNAs and delays in uploading information to the EMR. Several key policies and procedures were outdated, missing, or not reviewed annually, including those for admissions, infection control, skin/wound management, and water management. The QAPI plan provided during the survey was blank, and the NHA was unable to provide adequate answers regarding the lack of updated policies and procedures.