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/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.
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.
The facility did not maintain or implement an ongoing QAPI program, as there was no documentation of QAPI activities, committee meetings, or performance improvement projects since the last recorded QA committee meeting. The Administrator confirmed that required monthly meetings had not occurred, and a review of facility policy showed that such meetings and documentation were mandated to monitor and improve care quality.
A resident was administered Baclofen despite conflicting hospital discharge instructions and without physician clarification, resulting in adverse health effects and hospital transfer. The facility did not file an incident report or conduct a QAPI meeting to address the error, contrary to its policies.
The facility failed to maintain a plan that outlines the process for conducting QAPI and QAA activities, as required. Surveyors found no documentation or description of how these quality assurance activities are implemented.
The QAPI and QAA committees did not identify or discuss issues related to CPR and dialysis, as confirmed by the absence of these topics in meeting minutes and statements from the IDON. This failure meant that concerns affecting residents needing dialysis or CPR were not addressed by the facility's quality improvement processes.
The facility did not implement or maintain a comprehensive QAPI program, as confirmed by the Administrator during a review of records and the QAPI binder. There was a lack of appropriate monitoring, detail, follow-up, and documentation of QAPI activities, and no evidence was provided to show ongoing quality assurance efforts or results.
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