Failure to Sustain QAPI Oversight for Care Plan and Infection Control Deficiencies
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to maintain and monitor implemented procedures and interventions that were put in place to address previously identified deficiencies. Specifically, the committee did not sustain effective oversight for two deficiencies originally cited in December 2023: failure to follow a resident's care plan and improper infection control practices. Record reviews and interviews confirmed that these deficiencies persisted during the current survey, indicating that the corrective actions previously established were not maintained or monitored as required by the facility's own QAPI policy. For the care plan deficiency (F656), a Certified Nursing Assistant did not follow the comprehensive care plan when repositioning a sampled resident. Regarding infection control (F880), observations revealed that staff failed to prevent the potential spread of infection during PEG care for one resident and suprapubic catheter care for another, as noted in two out of five care observations. These findings were corroborated by record reviews, interviews, and policy reviews, confirming that the same issues identified in the prior survey were still present.