Failure to Identify and Address Resident Safety Risks in QAPI Program
Penalty
Summary
The facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) program to identify and address compliance concerns, specifically related to accident hazards and resident safety. Despite holding monthly QAPI meetings and daily interdisciplinary team discussions to review resident risks, the facility did not prevent repeat deficiencies or initiate adequate corrective actions for issues cited under F689 (Accident Hazards) and F867 (Quality Assurance Program) across multiple surveys. These deficiencies were cited at high levels of scope and severity, including immediate jeopardy to resident health or safety. A specific incident involved a resident with a known history of choking who was not provided with the required supervision and assistance during meal times, as outlined in their care plan. This failure to follow care planned interventions resulted in a situation where a serious adverse outcome was likely, rising to the level of immediate jeopardy. The facility's QAPI committee did not identify or address this lapse in supervision, contributing to the ongoing deficiency.