Failure to Maintain Effective QAPI Program and Incident Tracking
Penalty
Summary
The facility failed to develop, implement, and maintain an effective, comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) program. Despite having a policy and plan outlining the QAPI process, the facility did not consistently identify deficiencies, implement corrective actions, or evaluate the effectiveness of those actions. QAPI committee meeting minutes over several months showed repeated incidents of falls, including repeat falls and at least one fall resulting in a fracture, as well as medication errors and ongoing staffing challenges. However, there was a lack of Performance Improvement Projects (PIPs) in place for most of the review period, and when PIPs were implemented, there was insufficient documentation of tracking, trending, or evaluating their effectiveness. Additionally, the facility's accident and incident tracking log was incomplete, lacking essential information such as date, time, nature, and location of incidents, as well as actions taken and notifications made. Some residents experienced recurrent verbal and physical altercations and repeat falls that led to hospitalizations and fractures. Interviews with facility leadership confirmed that while data was collected and concerns were prioritized, the QAPI process did not result in timely or effective interventions to address ongoing issues, and documentation of corrective actions and their outcomes was lacking.