Infection Preventionist Failed to Participate in QAA/QAPI Meetings
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP), who also served as the Assistant Director of Nursing (ADON), participated in the Quality Assessment and Assurance (QAA) Committee meetings as required. Record review of QAA meeting sign-in sheets for several dates showed no documented attendance by the IP, despite the individual having assumed the IP role months prior. This was confirmed by the Assistant Administrator, who acknowledged the absence of the IP from these meetings and affirmed that participation is a standing requirement for the IP. Facility policy and the job description for the Infection Preventionist Nurse both specify participation in QAA meetings as a responsibility. The facility census indicated that 174 residents resided in the facility at the time of the deficiency. The lack of IP participation in QAA/QAPI programming was identified through interviews and record review, with the Assistant Administrator confirming the deficiency and its inconsistency with both facility policy and regulatory requirements.