Repeated QAPI Failures Lead to Ongoing Deficiencies
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct recurring quality deficiencies and ensure that plans to improve the delivery of care and services were effective. Despite developing plans of correction for previously cited deficiencies, the facility continued to have repeated issues identified in multiple surveys. These deficiencies included failure to provide confidentiality of residents' personal health information, inaccurate Minimum Data Set (MDS) assessments, improper care plan timing and revision, inadequate monitoring of urinary output, failure to maintain a medication error rate below 5 percent, improper labeling and storage of medications, and not serving palatable food at appropriate temperatures. The QAPI committee was responsible for reviewing audit results and ensuring compliance, but the same deficiencies were repeatedly cited in subsequent surveys, indicating that the committee's actions were ineffective. The report specifically notes that for each cited deficiency, the facility's plan of correction involved conducting audits and reporting the results to the QAPI committee. However, the current survey found that these measures did not result in sustained compliance, as the same issues persisted across multiple survey periods. The deficiencies were cited under specific federal tags (F583, F641, F657, F690, F759, F761, F804) and referenced state regulations, but there is no mention of individual residents' medical histories or conditions in the report.