Failure to Implement Effective QAPI and Medication Reconciliation Processes
Penalty
Summary
The facility failed to ensure that its Quality Assurance Committee developed and implemented an effective Performance Improvement Plan (PIP) to address quality deficiencies related to delayed laboratory result reporting, readmission medication reconciliation, and pharmacy Admission Medication Regimen Review (AMRR) after admission or readmission. The facility's QAPI policy required systematic monitoring and analysis of performance to improve resident outcomes, with specific benchmarks and input from staff, residents, and families. However, documentation and interviews revealed that these processes were not effectively followed in the case reviewed. A resident with a history of stroke, heart failure, and organ transplant was admitted to the facility and required close monitoring of tacrolimus levels as part of immunosuppressive therapy. Physician's orders specified regular lab draws and communication of results to the transplant team. After a hospital readmission, the resident's tacrolimus was discontinued in error, and there was a significant delay in obtaining and reporting lab results. The medical record did not show that the required AMRR was completed by the consultant pharmacist after the resident's return from the hospital. Additionally, the facility failed to communicate abnormal lab results to the transplant team in a timely manner, and the medication error was not promptly identified or addressed. Interviews with facility staff and external care providers indicated breakdowns in communication, lack of follow-through, and confusion regarding education provided to staff about medication reconciliation procedures. The Cardiology RN reported extensive difficulties in obtaining updated medication lists and lab results from the facility, and the facility's documentation did not reflect that the QAPI committee had identified or addressed all aspects of the deficiency, including missed lab draws, lack of AMRR, and communication failures. The PIP lacked established benchmarks or targets for monitoring performance improvement activities.