QAPI Committee Failed to Address Infection Control and Supervision Deficiencies
Penalty
Summary
The QAPI Committee failed to identify and address ongoing quality deficiencies, including inadequate supervision, ineffective infection control practices, and lack of staff competency in resident care. Meeting minutes from April, May, and June 2025 showed blank or incomplete documentation, with no evidence of infection control review or nursing department oversight. The committee did not perform root cause analysis, develop corrective plans, or ensure implementation of systems to maintain acceptable standards. There was also a lack of clinical guidance and oversight for resident care policies and procedures. During direct observation, an LPN used a multi-use blood glucose meter on one resident, cleaned it with a hand sanitizing wipe not recommended by the manufacturer, and then prepared to use it on another resident without proper disinfection. The facility could not provide documentation of staff education on blood glucose monitoring or cleaning protocols prior to the incident. Interviews with the DON and Administrator confirmed inconsistent or undocumented supervision and audits, and the Medical Director had not participated in a QAPI meeting to discuss the Immediate Jeopardy event.