Failure to Maintain Effective QAPI Program and Address Quality Deficiencies
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program, resulting in the inability to identify and address multiple quality deficiencies. The QAPI committee did not consistently meet as required, with missed meetings and inadequate attendance by key members such as the Infection Preventionist, Administrator, Director of Nursing, and Medical Director. The committee also failed to collect or analyze data related to critical areas, including resident change of condition, safety and maintenance of beds, infection control practices, activity provision, and abuse prevention. Sign-in sheets confirmed irregular meetings and lack of required interdisciplinary participation. As a result of these lapses, the facility did not ensure that resident treatments were completed and documented per physician orders, timely identification and assessment of changes in resident condition, proper assembly and maintenance of facility beds, implementation of infection control practices, provision of activities to meet resident needs, and maintenance of an environment free from abuse. The Nursing Home Administrator confirmed that the facility was not tracking compliance with physician notifications or care provided as ordered, and that no steps had been taken to address identified issues such as staff communication failures related to resident-to-resident abuse.