Failure of QAPI Oversight for Weekly Skin Assessments
Penalty
Summary
The facility failed to have an effective Quality Assurance and Performance Improvement (QAPI) committee that provided oversight and monitoring to ensure staff were performing weekly skin assessments for timely identification and treatment of pressure ulcers. Review of the QAPI committee meeting agendas and minutes for two meetings showed no indication that the committee identified the staff's failure to perform these assessments. The facility's policy required a comprehensive, data-driven QAPI program with regular review and prioritization of performance improvement projects (PIPs), but there was no evidence that a PIP addressing wound care or skin assessments was implemented in a timely manner, despite identified problems. Interviews revealed that the Regional Nurse Consultant had identified wound care issues and recommended a PIP, but the facility did not act on this recommendation. Additionally, required monthly audits for residents with wounds were not completed. The Administrator acknowledged that a PIP was not implemented until after the survey team arrived, and attributed missed actions to ongoing leadership changes. The noncompliance was determined to have caused or had the likelihood to cause serious injury, harm, impairment, or death to residents.