Lack of Documented Medical Director Participation in QA Committee Meetings
Penalty
Summary
The facility failed to provide evidence that the Medical Director attended and participated in the required quarterly Quality Assurance (QA) committee meetings. Review of the QA meeting sign-in sheets for four consecutive quarters showed that the Medical Director did not sign the attendance paperwork. During staff interview, the Administrator confirmed that the Medical Director was required to attend and participate in each quarterly QA meeting, and acknowledged that there was no documentation, aside from a statement that the Medical Director attended by telephone, to verify participation. The facility's policy specifies that the QA committee must include the Medical Director, Administrator, Infection Preventionist, Director of Nursing, and at least two other care partners. This deficiency had the potential to affect all 58 residents in the facility, as the required committee composition and participation were not documented as required.