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 effectively addressed these issues. Despite developing plans of correction after previous surveys, the facility continued to have repeated deficiencies in several areas, including failure to notify residents of changes in Medicare coverage, not providing services that meet professional standards, and not preventing accident hazards. The QAPI committee was responsible for reviewing audit results and monitoring compliance, but the same deficiencies were identified in subsequent surveys, indicating that the committee's actions were ineffective. Deficiencies were also noted in the areas of oxygen therapy, timely completion of nurse aide performance evaluations, accountability and proper storage of controlled medications, and ensuring that medications were properly labeled and stored. Additionally, the facility failed to maintain sanitary conditions in food storage and preparation, and did not ensure that clinical records were complete and accurately documented. These issues were cited under multiple federal tags, including F582, F658, F689, F695, F730, F755, F761, F812, and F842. The repeated nature of these deficiencies across multiple survey periods demonstrates that the QAPI committee did not successfully implement or sustain corrective actions. The committee's ongoing review and audit processes did not result in effective resolution of the cited issues, leading to continued noncompliance with state and federal regulations governing the quality of care and services provided.