Systemic Failure in Medication Management and QAPI Oversight
Penalty
Summary
The facility failed to ensure its Quality Assessment and Performance Improvement (QAPI) plan and program effectively identified, analyzed, and addressed adverse events and quality deficiencies, specifically related to medication management. Over a six-week period, there were more than 79 medication errors, with actual harm occurring to two residents: one required cardiac ICU admission and another experienced ongoing congestive heart failure (CHF) exacerbation. The facility lacked systems to prevent medication errors, notify providers, and investigate incidents, resulting in a widespread failure in medication management. Further review of facility records, including QAPI plans and meeting minutes from April to July 2025, revealed no focus on medication errors, no mention of medication error rates, and no evidence of quality activities to monitor or improve pharmacy services. The interim administrator confirmed that the QAPI minutes did not address medication errors, despite facility policy requiring root cause analysis and performance improvement plans when deficiencies are identified.