Repeat Deficiencies Due to Ineffective QAPI Oversight
Penalty
Summary
The facility failed to ensure that its Quality Assessment & Assurance (QAA) and Quality Assurance and Performance Improvement (QAPI) committee conducted effective performance improvement activities to sustain prior corrective measures related to medication administration. Despite having a QAPI plan that outlined regular review and revision of quality improvement processes, the facility did not maintain sufficient auditing and oversight, resulting in repeat deficiencies for pharmacy services (F755) and accuracy of medical records (F842) during the current survey, which had also been cited in the previous recertification survey. The QAPI plan required the committee to review data monthly and prioritize high-risk or problem-prone areas, but these processes were not adequately implemented to prevent recurrence of the deficiencies. Interviews with facility leadership, including the NHA, DON, and RNC, revealed that while the facility was actively working on other performance improvement projects, such as elopement and mechanical lift use, there was a lack of sustained focus on previously identified issues with medication administration and record accuracy. Leadership changes, high staff turnover, and insufficient follow-through by the leadership team were cited as contributing factors to the failure in maintaining improvements. The QAPI process did not continue effectively through these transitions, leading to ongoing noncompliance in the cited areas.