Failure to Analyze and Document QAPI Data and Action Plans
Penalty
Summary
The facility failed to ensure that data submitted to the Quality Assurance and Performance Improvement (QAPI) committee was properly analyzed and documented, resulting in a lack of oversight for identified areas needing improvement. Review of QAPI meeting minutes from March 2025 through May 2025 showed that department heads presented data on several key quality indicators, including pressure injuries above the national average, trends in falls, psychoactive medication use, increased assistance with activities of daily living (ADLs), rising antibiotic use for infection control, and six unplanned hospitalizations. However, there were no documented goals, action plans, or analysis of the data presented for these areas. An interview with the interim administrator confirmed that the QAPI meeting minutes lacked identification of goals, action plans, and data analysis for the issues brought forward. The administrator acknowledged the need for improvement and recognized the deficiencies in the QAPI process. Additionally, the facility's QAPI policy required the committee to oversee improvement areas, develop action plans, and analyze results, but documentation did not reflect these activities. No information was provided regarding the involvement of the medical director, as messages left were not returned.