Failure to Address Missed IV Antibiotic Order Through QAPI
Penalty
Summary
The facility failed to have a written Quality Assurance Performance Improvement (QAPI) plan in place to address the issue of not carrying out a physician's order for IV antibiotics for a resident following a surgical procedure. Despite identifying that the resident did not receive the IV antibiotic ordered by the orthopedic surgeon, the facility did not initiate a QAPI process to investigate or address the missed administration. The missed IV antibiotic order was not discussed in the QAPI meeting held after the issue was identified, and the Administrator was unaware of the problem until it was brought up during a complaint investigation. Facility records showed that QAPI meetings were held regularly and attended by key staff, but the specific issue of the missed IV antibiotic was not included in the agenda or addressed by the committee. The facility's policy indicated that the QAPI committee is responsible for overseeing and implementing the program, with the Administrator ultimately responsible for interpreting findings to the governing body. However, the lack of action and communication resulted in the resident not receiving the prescribed IV antibiotic for 35 days, leading to the identification of Immediate Jeopardy and substandard quality of care.