A facility's Administrator and governing body failed to ensure a QAPI plan addressed systemic issues with the bowel management program. Surveyors found the facility was not implementing the bowel management program or following the physician's order to address constipation, and an IJ was called after review of a resident's record showed the facility failed to carry out constipation interventions per policy and orders. The Administrator stated the QAPI committee met quarterly but had not identified bowel management issues until the survey team discovered the concern.
QAPI failed to address concerns about social services staffing qualifications, including the lack of a qualified SSD and SSA. The SSA stated she had only a HS diploma, and record review confirmed her education and role history. The job description required a bachelor's degree in social work or a related major with supervised experience, and the Adm confirmed the issue had not been addressed through the facility's QAPI program.
QAPI/QAA failed to identify system-wide issues involving infection prevention, dietary services, and environmental safety. The facility had no IPN, did not implement EBP for three residents with indwelling medical devices, lacked an updated Legionella water testing program, and had not employed a qualified DM for over a year. The Administrator confirmed the QAPI action plans did not address these systemic deficiencies.
QAPI and QA Committee Review Failures: The facility failed to implement its QAPI plan and prior POC for multiple deficiencies, including F554, F578, F583, F693, F755, F761, F803, F812, F880, and F881. Records reviewed with the Administrator did not show required audits and observations for F578 and F803 were completed, and the QA/QAPI binders did not show the audit findings were presented to the QA Committee for review and continued monitoring.
The facility failed to use its QAA/QAPI process to monitor and manage a temporary food service system put in place after the kitchen elevator became inoperable. Staff began transporting food and beverages by stairwell and using a conference room as a serving area, but no performance improvement project or monitoring was implemented for sanitation, infection control, or staff safety. Surveyors found expired food in the conference room refrigerator and cold beverages held above required temperatures, while the conference room lacked proper means to keep items cold. Food deliveries were left in the parking lot and carried by staff down the stairs to the basement kitchen. The RD’s sanitation audits did not include the conference room, and staff did not receive routine training or evaluation on safe food transport, fall prevention, or injury risk related to the new procedures, despite QA meetings discussing the elevator outage.
Missing QAPI Plan and Incomplete QAPI Data Review: The facility failed to maintain documentation and evidence of an ongoing QAPI program. During survey, the ADON stated the QAPI Plan in the binder was outdated, she did not have access to the current plan, and the ADM and DON were unavailable. The ADON described the QAPI Plan as the written guide for identifying problem care areas, reviewing data, and discussing issues such as falls, but the facility did not provide documentation of regular data collection and analysis for falls, which had been identified as a problem area.
QAA Committee failed to identify systemic issues affecting all residents, including 94 of 94 licensed nursing staff not being in-serviced or competency validated for CPR and emergency response, 3 of 3 RNAs not receiving annual in-service or competency validation, and 5 of 19 resident records containing inaccurate or incomplete documentation. The Administrator stated these issues were not identified by the committee, despite the facility QAPI policy requiring the committee to continually identify and address quality of care issues.
The facility’s QAPI Committee did not identify or address multiple quality of care issues, including systemic infection control and prevention problems, despite a written plan stating that data from various sources would be used to monitor care and services in areas such as infections and medications. The Administrator reported that the QAPI Committee met monthly and relied on input from department heads, grievances, the resident council, staff meetings, and an anonymous suggestion box, and that only ongoing struggles were escalated for QAPI monitoring. A performance improvement project for infection prevention was initiated only after surveyors were already on-site, and no other quality of care issues later found by surveyors had been captured by the QAPI Committee as areas for improvement, resulting in a systemic breakdown of the infection control and prevention program with potential for resident harm.
QAPI program failed to effectively include FANS. Surveyors found kitchen issues with pests, sanitation, and equipment maintenance, while staff interviews showed kitchen audits were inconsistent, not always done in the kitchen, and not thorough. The RD stated the kitchen safety and sanitation QAPI project had no strategy for improvement, no data to track progress, and was not quantifiable.
Incomplete QAPI Documentation and Meeting Records: The facility failed to maintain documentation and evidence of an ongoing QAPI program. The DON stated only a few QAPI meetings were documented after she restarted the process, and the DSD stated earlier QAPI activity was not properly documented and consisted only of sign-in sheets. The facility policy required QAPI minutes to include meeting details, reports and findings, action plans, conclusions, recommendations, and adjournment time.
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