Repeat Medication Error Rate Deficiency Due to Ineffective QAPI Oversight
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to sustain corrective actions to prevent recurrence of previously cited deficiencies related to medication error rates. During an annual recertification survey, the facility was cited for failing to maintain a medication error rate below 5%, and this deficiency was cited again during the current survey. Specifically, the facility had an 8% medication error rate in one survey and a 6.45% error rate in the most recent survey, both exceeding the regulatory threshold. The QAPI Committee, which is responsible for ongoing monitoring and oversight, did not ensure that corrective actions were effective in preventing the recurrence of this deficiency. Observations during the survey revealed two medication errors out of 31 opportunities. One resident was not instructed to rinse with water after receiving a steroid inhaler, and another resident received an incorrect dosage of Thiamine. These errors were identified through direct observation, record review, and staff interviews. The facility's policy and previous history of citations for the same issue were also reviewed, confirming that the deficiency persisted despite prior interventions.