QAPI Committee Failed to Address Systemic Issues in Room Changes and Bowel/Bladder Program
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI)/Quality Assessment and Assurance (QAA) Committee failed to adequately identify, develop, and implement plans of action for systemic issues related to resident room changes and the facility's bowel and bladder program. Specifically, the QAPI Committee began addressing resident notifications for room changes in May 2025, but did not revise corrective actions when it was found that notification sheets were not completed with reasons for the room changes. Additionally, while the QAPI Committee identified and developed a plan for the bowel and bladder program, the plan only included two-hour resident and bed checks, without further measures to address the program's effectiveness. These deficiencies were identified through observation, clinical record review, document review, and interviews.