Failure to Implement Effective QAPI Plan for Diabetes Management
Penalty
Summary
The facility's Quality Assurance and Performance Improvement Committee (QAPI) failed to implement an effective Performance Improvement Plan (PIP) for diabetes management, as evidenced by multiple incidents involving two residents with diabetes. In one case, a resident with Type 2 Diabetes Mellitus, legal blindness, epilepsy, and acute kidney failure was admitted and later discharged to an acute care hospital after experiencing uncontrolled hyperglycemia. Nursing staff failed to follow physician orders for insulin administration, with one LPN administering two separate 20-unit doses of insulin without a physician's order and without documenting the blood sugar readings or the insulin given. The nurse also failed to notify the physician as required when the blood sugar was above the specified threshold, and there was no documentation of these actions in the resident's medical record. Another resident with Type 2 Diabetes Mellitus and other complications had physician orders specifying that the physician should be notified if blood sugar exceeded a certain level. Despite multiple documented instances of blood sugar readings above this threshold, there was no evidence that the physician was notified as ordered. The medication administration records showed repeated high blood sugar readings and insulin administration, but the required notifications to the physician were not documented. The facility's QAPI policy outlines a process for tracking, measuring, and correcting performance issues, including the use of the Plan-Do-Study-Act (PDSA) cycle and regular reporting to the QA&A Compliance Committee. However, the events described demonstrate that the QAPI process was not effectively implemented or monitored in relation to diabetes management, as evidenced by the lack of adherence to physician orders, failure to document critical care actions, and absence of systematic follow-up on identified deficiencies.