QAPI Committee Failed to Address Documentation Inaccuracies
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Performance Improvement (QAPI) committee took effective action to identify and resolve systemic problems related to resident mood, behaviors, and side effects, as evidenced by inaccurate documentation of residents' current conditions. The QAPI plan required the committee to meet regularly, coordinate and evaluate QAPI activities, develop and implement corrective actions for identified deficiencies, and review and analyze data, including that from drug regimen reviews. Despite the Director of Nursing providing ongoing education to nursing staff on these topics, and the administrator acknowledging that the QAPI committee had identified documentation inaccuracies, the committee did not implement a Performance Improvement Plan (PIP) to address the issue. This deficiency affected all 49 residents in the facility.