Failure to Implement and Maintain Effective QAPI Program
Penalty
Summary
The facility failed to ensure the implementation and maintenance of an effective Quality Assurance and Performance Improvement (QAPI) program, as evidenced by the lack of good faith attempts to develop, implement, and sustain appropriate plans of action to address previously identified issues impacting resident safety and quality of care. Specifically, the facility did not follow through on the approved plans of correction from a prior survey for multiple areas, including resident rights, response to resident/family groups, environmental safety and cleanliness, activities of daily living for dependent residents, quality of care, pressure ulcer prevention and treatment, sufficient nursing staff, proper labeling and storage of drugs and biologicals, and sanitary food procurement and preparation. During the survey, it was found that the QAPI committee, led by the Administrator, met monthly and was aware of some issues such as staffing and kitchen sanitation. However, the committee was not aware of ongoing concerns in several other critical areas, including resident rights, group responses, environmental conditions, daily living care, pressure ulcer management, and infection prevention. This lack of awareness and follow-through resulted in repeat citations for the same deficiencies previously identified, indicating that the facility's QAPI processes were not effectively addressing or resolving these ongoing issues.