Failure to Maintain Antibiotic Stewardship, Medication Management, and QAPI Program
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program and did not ensure the pharmacy delivered medications or completed monthly drug regimen reviews for all residents over a one-year period. Staff reported that medications were not being received as ordered, leading them to obtain medications from a local store when the pharmacy could not supply them. Additionally, drug regimen reviews were inaccessible due to issues with the pharmacy's portal, resulting in no gradual dose reductions for psychotropic medications during the specified timeframe. The facility continued to use the same pharmacy until a new contract could be established, despite these ongoing issues. The facility also lacked a current and updated QAPI (Quality Assurance and Performance Improvement) plan, with the last documented goal dates over two years old. The infection preventionist role was not being fulfilled, as the previous staff member did not complete required duties and the newly hired nurse was not yet certified in infection prevention. QAPI activities were based on survey citations, grievances, and observations, but the plan had not been reviewed or revised in over two years. Staffing challenges were also noted, with one staff member working 11 consecutive days without a day off.