Failure to Monitor and Address Increase in Resident Falls
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) committee failed to monitor, review, and analyze data related to performance improvement issues, specifically regarding an increase in resident falls. During an interview, the DON acknowledged that there had been an increase in falls and that new interventions for fall prevention were needed, but also stated that the QAPI binder, which would address the increase in falls, could not be located following a change in administration. A review of the facility's QAPI policy indicated that the program is intended to measure care outcomes and implement performance improvement projects, but these processes were not effectively carried out in relation to the issue of falls. This lack of monitoring and analysis by the QAA and QAPI committee resulted in a failure to identify and address systemic issues related to resident falls, as required by facility policy.