Failure of QAA/QAPI Program to Identify and Address Widespread Deficiencies
Penalty
Summary
The facility failed to maintain an effective Quality Assessment and Assurance (QAA) and Quality Assurance and Performance Improvement (QAPI) program, as evidenced by the inability to identify, analyze, and address multiple critical care deficiencies. The QAA committee did not meet the required frequency, lacked required members such as the Infection Preventionist, and failed to track and trend data to identify performance improvement opportunities. As a result, the facility did not recognize or act upon compromised care and services, leading to a pattern of resident harm and immediate jeopardy situations. Specific deficiencies included the failure to identify, report, and prevent a pattern of resident-to-resident verbal and physical abuse, particularly involving a resident with known aggressive behaviors. Staff did not recognize these incidents as abuse, nor did they analyze the circumstances or implement effective interventions. Additionally, the facility failed to ensure timely provider notification for residents experiencing significant changes in condition, such as extremely low blood sugars, low blood pressures, and elevated blood sugars, which prevented appropriate clinical intervention. Other areas of deficiency included inadequate monitoring and supervision to prevent falls, resulting in repeated injuries and hospital transfers for several residents. The facility also failed to provide necessary behavioral health services, ensure accurate medication administration, and maintain effective infection prevention and control during a Norovirus outbreak, which affected a significant number of residents and staff. Furthermore, the facility did not ensure sufficient staffing to meet resident acuity and care needs, contributing to repeated falls and abuse incidents. These failures were acknowledged by facility leadership, who confirmed that no corrective actions had been attempted except for falls, and that existing performance improvement projects were ineffective.