Medication Errors Persist Despite QAPI Efforts
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) Program failed to effectively address and correct identified quality deficiencies related to medication errors. During a revisit survey, surveyors observed 10 medication errors out of 31 opportunities, affecting four residents. This repeated deficient practice was previously cited during a recertification survey, indicating ongoing issues with medication administration. The Director of Nursing (DON) was informed of the medication administration errors, which were documented under F759, Free of Medication Errors. Despite the facility's plan of correction, which included re-education of licensed nursing staff on the medication administration process, the errors persisted. The facility's QAPI program did not ensure that the medication error rate was maintained below the acceptable threshold of 5%. The facility's survey history and plan of correction records were reviewed, revealing that the Licensed Practical Nurses (LPNs) involved had undergone orientation and medication pass observations. However, these measures were insufficient in preventing the recurrence of medication errors, highlighting a lack of effective implementation and monitoring within the QAPI program.
Plan Of Correction
(1) What corrective actions will be taken for those residents found to have been affected by the deficient practice: AD Hoc QAPI Meeting was held on with the Administrator, Medical Director, Director of Nursing and interdisciplinary team members. The meeting agenda included the components of Regulations: F759 Free of Medication Error rates 5% or more and F867 QAPI and the areas of concerns communicated on survey exit by the Agency for Health Care Administration. (2) How you will identify other residents having the potential to be affected by the same practice and what corrective actions will be taken: The Regional Vice President of Operations re-educated the Administrator on regarding the components of this regulation with emphasis on ensuring quality assurance monitoring of facility processes related Medication Administration. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: QAPI meeting was conducted on and by the Administrator. Participation included interdisciplinary team members as well as the Medical Director. Meeting agenda included the components of Regulations: F-759 Free of Medication Error Rates 5 Percent or more F-867 QAPI. Education was provided by the Administrator to QAPI team members on related to the elements of the Quality Assurance and Process Improvement program and to ensuring quality assurance monitoring of facility processes related to Medication Administration. (4) How the corrective actions will be monitored to ensure the practice will not recur: The facility Administrator/designee will conduct a quality review of QAPI to ensure quality assurance monitoring of medication administration to ensure ordered medications are being administered in a timely manner and as prescribed by the physician weekly x 4 weeks, and then every 2 weeks x 2 months then PRN as indicated. The findings of this quality monitoring will be reported to the QAPI monthly. Quality Monitoring schedule will be modified based on findings with quarterly monitoring by the Regional Director of Clinical Services / designee.