Failure to Ensure Effective QAPI Oversight and Timely Implementation
Penalty
Summary
The facility's Quality Assessment and Assurance Committee (QAA) failed to provide effective oversight and implementation of the Quality Assurance and Performance Improvement (QAPI) plan. The administrator indicated that QAPI projects are initiated for areas of concern that require improvement, such as negative trends, but stated that skin issues were not considered a main focus because they had not previously been widespread. Despite a pressure injury occurring in a resident in February or March, the administrator did not believe the issue was widespread enough to warrant a QAPI project at that time. The QAA minutes from March indicated that weights and pressure ulcers were discussed, but the QAPI plan for skin was not initiated until April. The facility's policy requires the QAA committee to establish and implement a QAPI plan, identify and prioritize performance improvement projects, and monitor corrective actions. However, the delay in addressing skin issues and the lack of timely implementation of a QAPI project for pressure injuries demonstrated a failure to follow these procedures. This deficiency had the potential to allow recurring issues that could impact the quality of care for residents.