QAPI Committee Failed to Address Abuse and Supervision Deficiencies
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) committee failed to address, maintain, and develop an effective plan to correct identified problems related to abuse and accident following a facility-reported incident. Despite the identification of deficiencies concerning abuse and smoking supervision during an investigation, these issues were not included in the QAPI/QA Committee agenda. The Director of Nursing (DON) acknowledged that the problems were not addressed in the QAPI meeting and stated that the facility holds meetings every three months, with the last meeting not covering the identified concerns. The DON also recognized the importance of QAPI in preventing reoccurrences of abuse and ensuring a safe environment for residents, as well as the need for adequate staff supervision. The Administrator (ADM) confirmed that issues of abuse, smoking, and supervision were not reviewed in the previous QAPI meeting but indicated plans to include them in the next meeting. A review of the facility's policy and procedure for the QAPI Change Process showed that the facility is expected to use a systematic approach to performance improvement, including developing corrective action plans and tracking performance after identifying root causes. However, the committee did not follow these procedures after the deficiencies were identified, resulting in repeated deficient practices related to abuse and supervision.