Failure to Implement Effective QAPI Program and Address Multiple Facility Deficiencies
Penalty
Summary
The facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) program as required by its own policy and federal regulations. The QAPI committee did not identify or address a wide range of compliance concerns, including issues related to personal funds, survey results, bedholds, re-admissions, PASRR recommendations, quality of care, activities of daily living, activities, ancillary services, accidents/hazards, respiratory care, dialysis, mental/psychosocial concerns, drug regimen, dental care, hydration, snacks, arbitration agreements, immunizations, and maintaining a safe and comfortable environment. These deficiencies were identified through record review and interviews, which revealed that the QAPI committee's oversight was insufficient in monitoring and correcting these areas. Cross-referenced citations further detailed specific failures, such as not updating resident accounts with the current facility name, not making state inspection results readily available, not providing bed hold information at transfer, failing to re-admit residents after hospital transfers, not following PASRR recommendations, and not ensuring qualified staff provided necessary care (e.g., nail care for diabetic residents). Additional deficiencies included lack of personalized activity programs, untimely ancillary and dental services, inadequate supervision for residents at risk of choking, improper cleaning of CPAP machines, missing physician orders for dialysis, failure to identify trauma triggers, incomplete monthly medication reviews, insufficient hydration and snacks, improper arbitration agreement language, lack of immunization notifications, and unsanitary communal showers. Interviews with the Nursing Home Administrator (NHA) confirmed that the QAPI committee met monthly and reviewed certain areas, but failed to identify or address several of the cited concerns. The NHA was unaware of issues such as improper CPAP cleaning, insufficient snacks, and missed pharmacy medication reviews until they were brought up during the survey. The QAPI committee's process for identifying and following up on deficiencies was not effective in capturing or resolving these significant areas of noncompliance.