Failure to Identify and Address Quality Deficiencies Through QAPI Program
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program that identified and corrected quality deficiencies throughout the facility. The Director of Nursing (DON) was responsible for overseeing the quality management program, including QAA committee meetings and QAPI projects. However, during an interview, the DON stated that while each department manager conducted audits and discussed them with the QAPI committee, the committee was only focused on a limited set of issues such as restraints, skin infections, call light accessibility, and communication with medical providers regarding lab results. The DON was unaware of several areas of non-compliance, including medication administration and storage, timely provision of baseline care plans, accurate care plan revisions, completion of required assessments, proper handling of oxygen equipment, trauma-informed care assessments, safe food storage, and infection prevention and control practices. The QAPI committee had not identified or addressed these significant quality issues, and the DON confirmed that the QAPI process had not been effective in identifying problems that could impact resident care. The facility's QAPI policy stated that the program should encompass all care and services affecting clinical care, quality of life, resident choice, and care transitions, and that the governing body and management were responsible for identifying and prioritizing problems based on performance data. Despite this, the QAPI committee was not aware of or monitoring several critical areas of deficiency, as confirmed by the DON.