Failure to Use QAPI to Address Infection Control and Staffing During Influenza Outbreak
Summary
The facility failed to utilize its Quality Assurance and Performance Improvement (QAPI) program to identify, analyze, and correct systemic failures in infection prevention and control, as well as staffing, during an influenza outbreak affecting all 59 residents. The outbreak occurred over several days, during which the facility did not recognize the outbreak, did not initiate droplet precautions, failed to notify the local health department, and did not ensure that antiviral medications were administered as prescribed. There was also a lack of monitoring for staff illness and compliance with infection control measures, resulting in continued exposure and spread of influenza within the facility. Staff interviews and record reviews revealed that the QAPI Committee did not meet during or after the outbreak, and the incident was not discussed in any quality review process. The Medical Director was not fully informed about the number of affected residents, the implementation of infection control measures, or staffing shortages. The Infection Preventionist was not aware of the specific infection control measures implemented, did not maintain illness logs, and was unfamiliar with the facility's infection control policies. The Administrator and DON did not consider the outbreak an emergency, did not update the facility assessment or contingency plan, and did not verify the implementation of appropriate precautions or notification procedures. No internal investigation was conducted regarding missed medications, and the pharmacy and state agency were not notified. During the outbreak, there was insufficient licensed nurse coverage, with only one nurse responsible for 58 residents overnight, leading to missed medications and inadequate monitoring. The facility assessment lacked required details on staffing needs by shift and unit, and the contingency plan for staffing emergencies was not actionable. The Administrator and DON described the incident as isolated and made no changes to policies or procedures as a result. The QAPI process was not used to review or address the deficiencies in infection control or staffing, and no lessons were identified or learned from the incident.
Removal Plan
- The Administrator held an emergency Quality Assurance and Performance Improvement meeting with the Medical Director, Director of Nursing, Infection Preventionist, Medical Records nurse, Life Connections Coordinator, Wound Care nurse and others as part of the Interdisciplinary team to discuss findings from the State Agency, discuss immediate actions, and further interventions. Immediate actions were decided as in-servicing all staff on Abuse and Neglect, in-servicing nurses on medication administration and medication errors, in-servicing all staff on flu outbreak and isolation precautions. The Administrator would review policy for Quality Assurance and Performance Improvement for any changes needed and as re-education in policy. The Administrator would review and update facility assessment to identify updated needs to staff per unit and the contingency plan for emergencies. Administrative nurses would complete a 100 percent audit on all medication carts compared to medication orders to ensure all medications were accessible in the building. The Infection Preventionist would be in-serviced on the roles and responsibilities of an Infection Preventionist. Policies on Abuse and Neglect, medication administration, medication errors, QAPI, flu outbreak, isolation precautions, and the expectations of the Infection Preventionist were all reviewed and updated. Staff were in-serviced with new policies.
- The Administrator notified Medical Director of missed medications during QAPI meeting. All missed medications were reviewed with Medical Director during this meeting. No new orders were given. No adverse reactions were noted due to missed medications.
- The Director of Nursing began an in-service for all staff on the policies and procedures of Abuse and Neglect. No employee was permitted to return to work until they completed the in-service.
- The Director of Nursing began an in-service on medication administration and medication errors to educate all nursing staff. This in-service included procedures for when medication cannot be located anywhere in the facility. If medication is not available, staff should contact pharmacy and pull medication from emergency kit. Any missed medications are to be reported to the Director of Nursing and Medical Director immediately, an incident report is to be completed, the resident observed for any adverse reactions, and the family/resident representative is to be notified. Any tasks left undone are to be reported to relief during report for oncoming shift. No employee was permitted to return to work until they completed the in-service.
- Administrator and Director of Nursing reviewed Flu outbreak and Isolation precautions policy and procedures. The Director of Nursing began an inservice for flu outbreak and isolation precautions to educate all staff. All staff are to continue to monitor residents and staff for flu-like symptoms and report any findings to the immediate supervisor. No employee was permitted to return to work until they completed the in-service.
- The Administrator reviewed policy on Quality Assurance and Performance Improvement plan and policy for re-education purposes and to review new policy. The Quality Assurance and Performance Improvement plan and policy was reviewed with the facility's Interdisciplinary Team including the Administrator, Medical Director, Director of Nursing, Infection Preventionist, Medical Records nurse, Life Connections Coordinator, Wound Care nurse and others in a follow up Quality Assurance and Performance Improvement meeting.
- The facility Administrator began reviewing and updating the facility assessment to reflect correct staffing and supervision by shift and by unit related to the facility's acuity level. The Facility Administrator began updating the contingency plan for staffing emergencies within the facility assessment. The contingency plan will be initiated and is as follows: Facility will utilize On-call for staffing needs and call ins. On-call will notify Director of Nursing if not able to cover. Facility will utilize Consultants and/or transfer staff from other nursing facilities within partnership to assist and cover staffing needs. The new facility assessment was reviewed with the interdisciplinary team during follow up QAPI.
- The Infection Preventionist (IP) was included in an in-service held by the Director of Nursing for policy and procedures of outbreak surveillance and staff-illness tracking during an outbreak to be completed before beginning of their next shift. Due to this outbreak being finished, IP nurse was instructed to continue to monitor residents and staff for flu-like symptoms and to report to Director of Nursing any findings.
- The Director of Nursing, Medical Records nurse, and Wound Care nurse completed a 100 percent audit to compare the current medication orders to the medication on the carts and in medication rooms to verify all medications ordered were readily available in the facility. No negative findings during audit.
- The Administrator notified the Mississippi Department of Health of the flu outbreak.
- The Administrator held a follow-up QAPI meeting to discuss all immediate actions that were in place. All in-services and audits were completed. All staff would continue to monitor any residents or staff for flu-like symptoms, staffing would be reviewed daily to ensure all areas were covered according to the facility assessment, and daily reviews of missed medications would be reviewed each morning in clinical meeting.
Penalty
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The facility failed to ensure its QAPI Committee effectively addressed ongoing systemic problems in the Restorative Nursing Program. A PIP established a benchmark that 75% of residents on restorative programs would have documentation completed per their individualized care plans, yet quarterly QAPI reports over multiple years consistently showed completion rates below this benchmark, including findings of only 63% and 67% completion. The same issues were repeatedly identified, such as staff not consistently charting in the new system, CNAs not checking the Restorative book for updates, charge nurses not proactively ensuring daily restorative completion, and persistent time and staffing constraints. Despite these recurring deficiencies, the QAPI Committee continued the same interventions without revising the PIP, escalating the problem, or implementing new strategies, as confirmed by the DON during interview.
QAPI program failed to address repeated deficiencies. Review of the facility’s visit history showed repeated F689, Free of Accident Hazards/Supervision/Devices, and F880, Infection Prevention and Control, across multiple annual surveys and complaint investigations. The QAPI plan stated it would review sources of information for gaps or patterns in care systems, and the Administrator acknowledged the repeated deficiencies and said the facility would review and discuss plans to improve.
The facility failed to maintain an effective QAPI program for most of the review period, with no documentation of QAPI meetings, no Performance Improvement Plan, and no active Performance Improvement Projects despite multiple identified system issues. Resident Council minutes and grievance logs showed that administration was aware of ongoing concerns from residents and families that persisted without resolution. The Assistant Administrator reported no available QAPI documentation from prior leadership and confirmed that expected monthly QA and quarterly QAPI meetings were not occurring as required. Surveyors also found the facility lacked an effective staff training program, including required training on QAPI, effective communication, and behavioral health, contributing to substandard quality of care findings and an extended survey.
The facility failed to maintain an effective QAPI process to ensure required daily skilled assessments for residents receiving skilled services. A resident with multiple serious diagnoses, including paroxysmal atrial fibrillation, hypertensive heart disease, generalized muscle weakness, adult failure to thrive, and post-circulatory surgery aftercare, was receiving ordered PT and OT five times weekly but had no corresponding order for daily skilled notes and lacked skilled documentation on multiple days. An LPN/unit manager acknowledged that residents on therapy are expected to have daily skilled notes and that this resident did not. Although audits of skilled documentation were conducted, they covered less than half of the residents on skilled services and repeatedly focused on the same individuals, while this resident’s documentation was never audited, reflecting a deficiency in the facility’s QAPI monitoring of daily skilled charting.
A resident experienced progressive hypotension, hypoxia, and unresponsiveness consistent with sepsis over several hours, during which on-call and primary care providers ordered medication holds, diagnostic testing, and escalating IV fluids and O2 before eventually ordering hospital transfer. EMS documented sepsis with hypotension as the primary issue, and the resident later died in the hospital with sepsis listed as the cause of death. The DON reported that early sepsis recognition and immediate action are facility nursing standards but acknowledged it would be difficult to say the transfer was timely. She could not locate evidence that the case was reviewed by the QAPI committee, discussed in the weekly risk management meeting, or that any quality improvement plan or action plan was developed, despite a facility QAPI policy requiring systematic identification and monitoring of high-risk, problem-prone processes.
QAPI process failed to address PASRR deficiencies after a prior F644 citation. A resident’s record showed a PASRR completed by a hospital that listed suspected anxiety disorder and use of antidepressant and antianxiety meds, but the resident was later admitted with PTSD and then started on Abilify without an updated PASRR evaluation in the record. The DON confirmed no updated PASRR had been completed since the hospital screening, while the Administrator stated tagged-area audits were to be tracked through QAPI.
Ineffective QAPI Oversight of Restorative Nursing Program
Penalty
Summary
The deficiency involves the facility’s failure to ensure its QAPI Committee effectively identified, monitored, and corrected ongoing systemic issues in the Restorative Nursing Program. The facility’s Quality Management Plan stated that the Interdisciplinary Quality Program was intended to provide a systematic, coordinated, facility‑wide approach to quality care and sustainability, including resolving identified areas of concern. A Performance Improvement Plan (PIP) initiated in January 2024 set a benchmark that 75% of residents on a Restorative Program would have documentation completed per their individualized plan of care. However, quarterly QAPI reports from 2024 through 2026 repeatedly documented that this benchmark was not met, including specific findings such as only 63% of residents having documentation of receiving restorative services in one quarter and a 67% completion rate in another, both below the 75% benchmark. Record and PIP review showed that the same issues were identified in every quarterly report from January 2024 through March 2026, including staff not always charting what they did in the new charting system, CNAs not consistently checking the Restorative book for changes, charge nurses not being proactive in ensuring daily restorative service completion, and ongoing time constraints and staffing issues. Despite these repeated findings and the continued failure to meet benchmarks across multiple consecutive quarters, the QAPI Committee continued the same interventions quarter after quarter without revising the PIP, escalating the issue, or implementing new strategies. During an interview, the DON confirmed that the plan had been in place for several years and that audits were conducted monthly and reviewed with the committee, but the documentation showed no evidence of effective corrective actions or sustained performance improvement related to restorative services.
QAPI Program Failed to Address Repeated Deficiencies
Penalty
Summary
The facility failed to ensure a comprehensive and effective QAPI program and did not have a plan that described the process for conducting QAPI and QAA activities. Review of the DIAL website visit history showed repeated deficient practices identified during the facility’s annual survey and complaint investigation on 3/27/25 and during the annual survey, complaint, and facility-reported incident investigation on 4/19/26. The repeat deficiencies included F689, Free of Accident Hazards/Supervision/Devices, which had been repeated in the previous three consecutive annual surveys, and F880, Infection Prevention and Control, which had been repeated in the previous four consecutive annual surveys. The facility’s QAPI plan stated that it would review sources of information to determine whether gaps or patterns existed in systems of care that could result in quality problems or opportunities for improvement. During an interview on 4/23/26 at 1:28 PM, the Administrator acknowledged the repeated F689 and F880 deficiencies and stated the facility would review and discuss plans to improve.
Failure to Maintain Effective QAPI Program and Staff Training
Penalty
Summary
The facility failed to implement and maintain an effective QAPI program and QAA activities for three of four quarters reviewed, affecting all residents. Surveyors found no documentation that multiple identified system issues, including those related to maintenance and pest control, were being discussed during QAPI meetings. There was no documentation of a Performance Improvement Plan and no QAPI team meetings for most of the review period. Review of Resident Council minutes and grievance logs showed that administration was aware of ongoing issues and concerns voiced by residents and families, yet these issues continued for several months without resolution. Substandard quality of care was identified, prompting an extended survey. During interviews, the Assistant Administrator reported having no information about QAPI activities prior to January 2026 and stated that the current administrative staff could not locate any QAPI documentation from the previous administrator. She indicated that the facility was expected to meet monthly for Quality Assurance and quarterly for QAPI, but confirmed there was no current Performance Improvement Project in place. The extended survey also determined that the facility did not have an effective training program, with failures in required staff training on QAPI, effective communication, and behavioral health. These findings demonstrated that the facility did not have an operational, documented, or effective QAPI and staff training system in place during the review period.
Failure to Ensure Daily Skilled Assessments Through Effective QAPI Monitoring
Penalty
Summary
The facility failed to maintain an effective, comprehensive QAPI program related to ensuring daily skilled assessments for residents receiving skilled services. One resident was admitted with multiple significant diagnoses, including paroxysmal atrial fibrillation, hypertensive heart disease without heart failure, generalized muscle weakness, adult failure to thrive, and a need for surgical aftercare following circulatory system surgery. The resident had active physician orders for occupational therapy five times a week for 30 days and physical therapy five times a week for 30 days, but there was no order for a skilled daily note to be completed. Review of the resident’s assessments showed there was no skilled documentation on multiple specific dates while the resident was receiving these skilled services. During interviews, an LPN/unit manager stated that daily skilled notes are done for residents receiving therapy and confirmed that this resident was not receiving daily skilled assessments, clarifying that a progress note does not take the place of the assessment. The DON reported that the facility had identified an issue with skilled documentation and that the expectation was that anyone getting therapy should have a daily skilled assessment. Review of QAPI-related audits of skilled documentation showed that only 12 of 31 residents receiving skilled services had been audited over several dates, with some residents audited repeatedly while others, including this resident, were not audited at all. The DON confirmed that the same residents were being audited and that this resident’s clinical documentation had not been reviewed, demonstrating a failure of the QAPI process to comprehensively monitor and ensure completion of required daily skilled assessments.
Failure to Use QAPI After Delayed Sepsis Response
Penalty
Summary
The deficiency involves the facility’s failure to implement an effective QAPI process following a serious clinical incident involving a resident who exhibited signs and symptoms of sepsis and was not transferred to the hospital in a timely manner. On 9/1/24 at 6:27 a.m., the weekend on-call licensed provider was notified that the resident’s blood pressure was 84/49, and orders were given to hold aspirin and antihypertensive medications, check for blood in the stool, and perform hourly blood pressure checks. By 7:30 a.m., the resident’s blood pressure had decreased to 80/41, oxygen saturation was 84% on room air, and the resident was unresponsive to verbal stimuli; the resident’s neurological status of being unresponsive did not change throughout the day. The primary care physician (PCP) was notified and ordered IV fluids at 100 ml/hr. At 8:00 a.m., the resident’s blood pressure was 82/38 and oxygen saturation was 93% on 4 L O2. At 9:30 a.m., the PCP ordered additional IV fluids. At 10:00 a.m., the resident’s blood pressure was 85/43, heart rate was 132, and oxygen saturation was 85–90% on 5 L O2, with IV fluids continuing. At 11:08 a.m., blood pressure was 79/40 and oxygen saturation was 99% on 8 L O2, and at 12:00 noon, blood pressure was 81/41. The PCP then ordered transfer to the hospital. EMS records show the facility called for emergency assistance at 12:23 p.m., with EMS documenting a primary impression of sepsis and hypotension as the primary sign/symptom. The resident’s death certificate listed time of death at the hospital as 3:37 p.m. and sepsis as the cause of death. During an interview on 4/8/26, the DON stated that recognizing early signs and symptoms of sepsis and taking immediate action is a nursing standard in the facility and acknowledged it would be very hard to say the resident was transferred in a timely manner. The DON reported she could not find specific evidence that the sequence of events surrounding the resident’s discharge was reviewed by the QAPI committee or that a quality improvement plan was considered after the delay in treatment. She stated that weekly risk management meetings, considered part of the QAPI process and used to discuss all discharges from the previous week, had no documented evidence of review of this resident’s case, and she was not aware of any action plan developed regarding the situation. Review of the facility’s QAPI policy showed that the Administrator is responsible for directing and implementing a QAPI plan that systematically identifies actual or potential areas of risk or deficiency and targets high-risk, high-volume, or problem-prone processes, but there was no documentation that this incident was addressed through that process.
QAPI Process Failed to Address PASRR Deficiencies
Penalty
Summary
The facility failed to implement effective quality assurance processes to address PASRR deficiencies, resulting in F644 being cited in 2025 and again during the current survey. The facility’s CASPER report showed a prior citation for F644 Coordination of PASRR and Assessments in March 2025. The CMS 2567 POC for that citation stated that Administrative Nurses and the Social Service Designee would continue reviewing PASRR assessments during the referral process to ensure new admissions had all mental health diagnoses included before admission, and that the Social Service Coordinator or designee would audit admissions monthly for three months to ensure all diagnoses were listed on the current PASRR. A review of Resident #38’s clinical record showed a PASRR completed by a local hospital on 9/02/25 before admission that listed suspected anxiety disorder and use of antidepressant and antianxiety medications. The resident was admitted with a physician order for antidepressant medication for PTSD, and on 12/19/25 a physician order was written to start Abilify every morning. During interview, the DON stated the facility did not have any updated PASRR evaluation for Resident #38 since 9/02/25. The Administrator stated that audits from tagged areas would be placed, completed, and tracked through the QAPI program for compliance, and the QAPI policy stated the Administrator was responsible for ensuring the program was defined, implemented, maintained, and addressed identified priorities, with regulatory outcomes and survey results monitored and trended.
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