Failure to Sustain QAPI Corrections Leads to Repeat Deficiencies
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Performance Improvement (QAPI) program effectively self-identified deficiencies and developed or implemented effective plans of action to sustain corrections for previously cited deficiencies. Record review showed that the QAPI committee was responsible for compliance and continuous improvement, but repeat deficiencies were identified in multiple areas, including resident rights, investigation and prevention of alleged violations, maintaining a safe and homelike environment, care plan timing and revision, activities of daily living, quality of care, prevention of decrease in range of motion and mobility, accident hazards, nutrition and hydration status, and psychotropic medication use. These deficiencies were noted as repeat findings from previous Statements of Deficiencies on multiple survey dates. During an interview, the Administrator acknowledged the repeat deficiencies and stated an inability to speak to actions taken by prior leadership. The Administrator indicated that the QAPI team's expectation was to follow established processes, hold staff accountable, and maintain consistency, with a current focus on management staff retention. The report does not mention specific residents or patient conditions related to the deficiencies.