Infection Preventionist Absent from Required QAPI Meeting
Penalty
Summary
Facility staff failed to ensure the attendance of the infection preventionist at one of five reviewed QAPI (Quality Assurance Performance Improvement) meetings, specifically the Q4 2024 meeting. Review of QAPI meeting sign-in sheets did not show the infection preventionist present at this meeting. Interviews with the director of clinical services revealed that the infection preventionist had resigned in November 2024, and although the assistant director of nursing was covering the role at the time, this individual was not present at the meeting. The executive director confirmed that QAPI meetings are held at least quarterly and are attended by an interdisciplinary team, which should include the infection preventionist as per facility policy. The facility's QAPI policy requires the infection preventionist to be a member of the Quality Assessment and Assurance Committee.