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17. After investigating the problems below, the QAA committee determines that a PIP is needed to change processes(s) leading to the undesired outcomes. Which process would the QAA committee select?

 

a A resident acquired a pressure ulcer, which was found on night shift. A gap in process did NOT lead to the resident acquiring this pressure ulcer. 

 

b Four residents sitting at the same table have complained about the dinner meal being served cold once during the month. A new cook did not know to hold this table’s dinner when the residents went on a monthly outing and returned after dinner. 

 

c Four new residents had falls with fractures on the night shift within one week. The admission fall risk assessment information and history of daily routines are not being incorporated into the care plan or shared with certified nursing assistants. 

 

d Ten residents have complained about not having enough clean towels in the morning on a daily basis. The order of towels was found to be on back order. 

 

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