Failure to Implement Effective QAPI for Pharmaceutical Services
Penalty
Summary
The facility failed to maintain an effective, comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) program specifically related to pharmaceutical services, resulting in ordered medications not being administered to multiple residents. The QAPI plan, last revised in 2014, was intended to monitor and improve the quality and safety of resident care, but the facility did not implement a performance improvement plan when ongoing issues with medication procurement from the contracted pharmacy persisted for at least five months. The Director of Nursing (DON) and other staff acknowledged that there was no improvement in obtaining medications despite repeated communications with the pharmacy, and no system was in place to confirm receipt of ordered medications. One resident with a history of diabetes, foot ulcer, traumatic amputation, and urethral erosion did not receive prescribed pain management medications (Biofreeze and Lidocaine gel) for the majority of scheduled doses over several weeks. The resident reported ongoing pain during catheter care and frequent lower extremity pain. Staff interviews confirmed that these medications had not been available from the pharmacy for an extended period, and the process for reporting unavailable medications did not result in resolution or improvement. Another resident with complex medical conditions, including myasthenia gravis, cancer, and chronic respiratory failure, did not receive critical medications such as an immunosuppressant, an antiprotozoal agent, and a dry mouth treatment for extended periods, as documented in the medication administration records. The resident reported that staff consistently informed them that medications were on back order. A third resident with hypertension did not receive a prescribed antihypertensive medication for multiple consecutive days after admission, with staff confirming that the medication had never been available in the facility. Despite repeated orders and communications with the pharmacy, the facility did not initiate a performance improvement project or develop an alternative solution to address the ongoing pharmaceutical service failures.