Failure to Implement Effective QAPI System for Adverse Event Monitoring
Penalty
Summary
Facility staff failed to implement an effective system for identifying, reporting, tracking, investigating, and analyzing adverse events, as determined during a recertification survey. The QAPI plan was found to lack a systematic approach for problem identification and data analysis. During interviews, the DON stated that the QAPI team met monthly and focused on staffing concerns, but could not provide documentation or data to demonstrate monitoring or analysis of staffing issues. Additionally, when asked about the process for addressing the lack of CPR certification among nursing staff, the facility was unable to provide documentation regarding when the issue was discovered, how it was being monitored, or what actions were taken to address it. Requested data and records were not available for review in the QAPI documentation.