Failure to Use QAPI Data for Fall Prevention Leads to Resident Harm
Penalty
Summary
The facility failed to develop and implement an effective Quality Assurance and Performance Improvement (QAPI) program, specifically by not utilizing resident fall data to establish a comprehensive safety plan for fall prevention. Despite tracking the number of falls and using the data to incentivize staff with rewards such as pizza parties for fall-free periods, the administrator was unable to articulate how this data was used to ensure an effective fall prevention program. The QAPI committee's activities did not translate into actionable strategies to address repeated falls, as required by the facility's own QAPI policy and job descriptions. As a result of these deficiencies, a resident experienced multiple unwitnessed falls over several months, leading to repeated injuries, including lacerations that required emergency department visits and sutures. The resident ultimately suffered a subdural hematoma following a fall, which contributed to their death. The facility's failure to analyze and act upon fall data as part of its QAPI process directly resulted in ongoing harm to the resident.