| 2907 |
KEYSTONE RIDGE POST ACUTE NURSING AND REHAB |
285238 |
7501 KEYSTONE DRIVE |
OMAHA |
NE |
68134 |
2019-04-22 |
865 |
K |
0 |
1 |
BJ6K11 |
LICENSURE REFERENCE NUMBER 175 NAC 12-006.07C Based on record review and interview; the facility Quality Assurance Improvement Program (QAIP) failed to identify ongoing issues relevant to F578, F582, F584, F602, F609, F656, F658, F732, F741, F761, F880 and F923 and implement effective plans of action to identify and correct the deficient practice. The QAIP failed to ensure repeated deficiencies at F677, F679, F689, F690, F759, F760, F812 and F835 were corrected and the correction maintained. The facility staff identified a census of 60. Findings are: Record review of the facility QAPI Program sheet dated 1-17-2019 revealed the following information: -#3. The outcome of the QAIP is the quality of care and quality of life of the residents. -#4. QAIP includes all employees, all departments and all services provided. -#5. QAIP focuses on systems and process's. The emphasis is on identifying system gaps. -#6. Decisions are based on data, which includes the input and experience of caregivers, residents, healthcare providers and families. -Program Purpose: -The major purpose of the QAPI committee is to improve the residents' total environment and all aspects of their lives-physical, social, physiological, spiritual and intellectual; and to improve the effectiveness, efficiency and quality of healthcare services delivered to the residents. On 4-11-2019 at 7:35 AM an interview was conducted with Licensed Practical Nurse (LPN) I. When asked if LPN J was aware of what the QAPI committee was working on, LPN I reported not aware of what the issues were. On 4-11-2019 at 7:40 AM an interview was conducted with nursing Assistant (NA) C. During the interview, NA C reported now being aware of what the QAIP committee was working on. On 4-11-2019 at 7:42 AM an interview was conducted with NA [NAME] During the interview NA J reported not being aware of what the QAIP committee was working on. On 4-11-2019 at 7:50 AM an interview was conducted with NA K. During the interview NA K was not able to identify any issue the QAIP committee was working on. On 4-11-2019 at 8:00 AM an interview was conducted with LPN [MI] During the interview, LPN L was able to identify the facility had a QAIP proram, however, LPN L was not able to identify any issues the QAIP was working on prior to the start of the annual survey. |
2020-09-01 |