Failure to Implement Effective QAPI Oversight for Pressure Injury and Quality of Care Deficiencies
Penalty
Summary
The facility failed to maintain and develop an effective Quality Assurance Performance Improvement (QAPI) plan to correct identified and potential problems related to pressure injuries and quality of care. Specifically, the facility did not provide effective oversight or ensure implementation of its plan of correction for deficiencies regarding timely assessment and treatment of pressure injuries, as well as proper oral care as ordered by a physician. The CMS 2567 survey report documented that the facility failed to assess a resident's pressure injury and initiate wound care treatment in a timely manner, and also failed to assess a resident's tongue and administer prescribed mouthwash for dry mouth and throat. These deficiencies were identified during both the previous and most recent recertification surveys. Interviews with the DON and Administrator confirmed that, despite conducting regular wound meetings and implementing skin sweeps, the facility continued to experience repeat deficiencies in these areas. The DON acknowledged that the current plan of correction was not effective in addressing the issues, and the facility's QAPI committee was not successful in coordinating, monitoring, and evaluating performance improvement projects to achieve the intended quality of care outcomes.