QAPI Committee Failed to Sustain Corrective Actions for Labeling and Storage Deficiencies
Penalty
Summary
The facility's QAPI committee failed to implement effective corrective actions to address previously identified deficiencies, as evidenced by ongoing issues with labeling and dating of tube feeding bags, medications, and food items. During a recertification and complaint survey, the facility was cited for not labeling and dating a tube feeding bag, not labeling opened medications, and not ensuring food was sealed, labeled, and dated with a use-by date. These deficiencies were observed again during follow-up, including an unlabeled tube feeding bag for a resident, opened vials of insulin on two medication carts without opened dates, and unsealed, unlabeled food items in the kitchen. Review of the facility's QAPI meeting minutes showed that while the committee discussed the plan of correction and audit tools, the only documentation was a copy of the CMS-2567 attached to the minutes. During an interview, the Administrator stated that the committee believed the audits were effective, but was unable to explain the continued presence of the same deficiencies. The lack of effective follow-through and sustained corrective action by the QAPI committee contributed to the ongoing noncompliance affecting all residents in the facility.