Failure to Analyze and Document QAPI Data and Actions
Penalty
Summary
The facility failed to ensure that data submitted to the Quality Assurance and Performance Improvement (QAPI) committee was properly analyzed and documented. Although department heads regularly brought data on topics such as medication errors, falls, pressure ulcers, weight loss, pharmacy services, infection control, admissions and discharges, staff agency use, and adverse event monitoring to the QAPI meetings, only falls and pressure ulcers had benchmark goals identified. Even for these areas, there was no analysis of the data or documentation of actions the facility would take to achieve the goals, nor was there monitoring to determine if the goals were met or if continued QAPI oversight was needed. For all other areas, there were no documented benchmarks, data analysis, or action plans. Review of QAPI meeting minutes from multiple months confirmed the lack of documented benchmarks, analysis, and action plans across a range of quality indicators. An interview with the regional administrator confirmed that the facility had not identified goals, action plans, or analyzed data brought forth in the QAPI meetings. The facility's own QAPI policy required oversight, action plan development, and analysis, but these steps were not documented or implemented as required.