Repeated QAPI Failures Lead to Ongoing Deficiencies in Wound Care, Medication Management, and Documentation
Penalty
Summary
The facility failed to establish and maintain an effective Quality Assurance and Performance Improvement (QAPI) program, resulting in repeated deficiencies across multiple surveys. Specifically, the facility did not conduct quarterly QAPI meetings to review audits, systems, and procedures, and failed to monitor and evaluate action plans previously developed to correct identified issues. This lack of oversight led to the recurrence of deficiencies related to pressure ulcer treatment, medication labeling and storage, and accurate documentation of medication administration. The Administrator acknowledged responsibility for the QAPI program and admitted that meetings were cancelled when the Medical Director was unavailable, and that follow-through on corrective plans was lacking. During the surveys, it was found that the facility failed to obtain and implement physician orders for the treatment of a Stage 2 pressure ulcer, which progressed to an unstageable wound. Additionally, staff did not consistently record opened dates on medications or discard expired medications found on treatment and medication carts and in storage areas. There were also failures to maintain accurate medical records, particularly in documenting medication administration. These deficiencies were observed repeatedly over three federal surveys, and the Administrator cited frequent changes in key staff positions as a contributing factor to the facility's inability to sustain compliance.