Failure to Monitor and Audit QAPI Projects
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program by not adequately monitoring open QAPI projects to determine if corrections or revisions were necessary. During a review and interview with the Director of Nursing (DON), it was found that several nursing Quality Assurance (QA) projects had been initiated, but ongoing monitoring and audits were not consistently performed as required. For example, a QA project for Gradual Dose Reductions (GDRs) was opened with the intent to meet with the pharmacy consultant monthly and as needed, but no monitoring or audits were conducted. The DON confirmed that she had not been monitoring or auditing the GDRs project. Another QA project for weekly body audits was also not properly monitored. Although a schedule for daily body audits was placed at each nurses' station and staff were in-serviced, monitoring that began in early June ceased by mid-July due to the absence of the treatment nurse. Similarly, a QA project for expired medications required weekly random observations, but after initial monitoring in June, no further observations were conducted through the end of July. The DON acknowledged awareness of these deficiencies and confirmed that adequate monitoring of the QA projects had not been conducted prior to the survey. These failures had the potential to affect all 73 residents in the facility.