Failure of QAPI Committee to Identify Systemic Infection Control and Quality of Care Issues
Penalty
Summary
The facility’s Quality Assurance Performance Improvement (QAPI) Committee failed to identify multiple quality of care issues, including systemic infection control and prevention problems, despite having a written QAPI plan stating that the facility would monitor care and services using data from multiple sources and consider areas such as infections and medications. During interview, the Administrator reported that the QAPI Committee met monthly and relied on information from department heads, grievances, the resident council, monthly all-staff meetings, and an anonymous suggestion box, and that issues considered ongoing struggles would be taken to QAPI for monitoring. The Administrator further stated that a performance improvement project for infection prevention was only initiated after the survey had already begun, and confirmed that none of the other quality of care issues identified by the survey team had been captured by the QAPI Committee as areas needing improvement. This failure of the QAPI and Quality Assessment and Assurance (QAA) processes to detect and address multiple quality of care concerns, including infection prevention and control, was cited as resulting in a systemic breakdown of the infection control and prevention program, which potentially could have led to harm of vulnerable residents and other poor outcomes for residents in the facility’s care.
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