Repeat Infection Control Deficiency Due to Lapses in QAPI Oversight
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to sustain corrective actions to prevent the recurrence of previously cited deficiencies related to infection control practices. Despite having been cited for failing to maintain infection control during wound care in a prior annual recertification survey, the facility was cited again for the same deficiency during the current survey. Record reviews confirmed that the facility had previously received a citation for failing to prevent the possibility of the spread of infection during wound care. During the current survey, staff were again observed not following appropriate infection prevention and control practices for two residents. Specifically, a Registered Nurse did not perform hand hygiene or don appropriate personal protective equipment (PPE) while administering medications through a PEG tube to a resident who required enhanced barrier precautions. Additionally, an LPN failed to follow enhanced barrier precautions and glove-changing protocols during wound care for another resident. These lapses were identified through direct observation, staff interviews, and record reviews, demonstrating a failure to maintain consistent infection control practices as required.