Failure to Implement and Monitor QAPI Interventions for Resident Safety
Penalty
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) committee implemented and monitored effective interventions to maintain a safe environment for residents. Despite having a policy in place requiring systematic monitoring and evaluation of resident care, the QAPI committee did not maintain documentation of meeting minutes or evidence of monitoring the effectiveness of interventions following a serious safety incident. Staff interviews and observations revealed inconsistent compliance with education and monitoring related to electrical safety, and there was a lack of consistent oversight for electrical devices and power cords used by residents. An event occurred in which a resident was found in bed with third-degree electrical burns after urine contacted an energized power strip positioned in the bed. The resident required transfer to the emergency room for evaluation. Subsequent observations during the survey found ongoing noncompliance, with residents having charging cords in bed or attached to handrails without appropriate care plan interventions. The Maintenance Director confirmed inconsistent monitoring of electrical devices, and the Administrator was unable to provide QAPI meeting minutes or evidence of performance improvement evaluation related to the incident.