Failure to Correct and Prevent Ongoing Medication Administration Deficiencies
Penalty
Summary
The facility failed to effectively carry out Quality Assurance activities to ensure that previously identified deficiencies, specifically related to medication administration, were corrected and did not persist. Despite the existence of a QAPI plan and regular meetings of the QAPI team, deficiencies in medication administration were identified during a prior survey and again during a subsequent complaint survey. The QAPI team collected data through various channels, including an online program, suggestion boxes, grievance forms, and state agency findings, and prioritized issues affecting residents' quality of life or rights. However, the facility continued to struggle with the same issues, indicating that the measures taken were not sufficient to resolve the deficiency. Interviews with the Administrator and the DON revealed that the QAPI team reviewed medication administration practices, including rights, refusals, and missed medications, and conducted ongoing audits following the previous survey. The QAPI plan outlined responsibilities for reviewing data and prioritizing improvement opportunities, but the recurrence of the same deficiency suggests that the process was not effective in preventing ongoing problems with medication administration. The report does not mention any specific residents or their medical conditions at the time of the deficiency.