Failure to Monitor Effectiveness of Interventions for Timely Resident Care
Penalty
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) committee monitored interventions related to delays in resident care, specifically regarding timely response to call lights. Multiple grievance reports documented concerns from residents about delays in receiving assistance after activating call lights. These grievances were noted on several occasions, with residents expressing dissatisfaction with the timeliness of care and customer service. Despite these documented concerns, the facility's QAPI committee did not include call light response or customer service as areas of focus in their most recent program reviews. While the Director of Nursing (DON) provided in-service education to staff on the importance of timely call light response, there was no system in place to evaluate whether these interventions were effective in improving response times or overall resident care. Interviews with the Administrator and DON confirmed the absence of a monitoring or evaluation process for these corrective actions. The facility's policy and procedure for the QAPI program outlined responsibilities such as collecting and analyzing performance data, identifying and monitoring facility systems, and evaluating performance improvement projects. However, the actual practice did not align with these responsibilities, as the QAPI committee did not track or assess the effectiveness of interventions implemented to address the identified delays in resident care.