Repeated Deficiency in Resident Nail Care Due to Ineffective QAPI Implementation
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) plan, as evidenced by a repeated deficiency related to resident grooming. Specifically, the facility was cited for not ensuring that a resident's nails were clipped, an issue that was previously identified in a prior annual recertification survey. During the most recent survey, a resident was observed with long and jagged toenails and expressed that she had not received assistance with nail care, despite requesting help. This observation was supported by staff and resident interviews, as well as a review of facility policies and prior statements of deficiencies. Interviews with facility leadership revealed a lack of clarity regarding the reasons for non-adherence to the previous plan of correction for Activities of Daily Living (ADL) care. The Administrator was unable to specify why the plan was not being followed, while the DON suggested that staff may be overlooking nail care during routine grooming. The facility's policy on QAPI, which outlines the establishment of performance indicators and systematic actions to improve performance, was reviewed but not effectively implemented to prevent recurrence of the deficiency.