Failure to Implement Comprehensive QAPI Program and Oversight
Penalty
Summary
The facility failed to implement a comprehensive Quality Assurance and Performance Improvement (QAPI) program that addressed all systems of care, resulting in significant deficiencies. Specifically, the facility did not identify or address problems related to the prevention and treatment of pressure ulcers, physician supervision of resident care, administration, and oversight by the Medical Director. This lack of oversight led to a resident developing a facility-acquired stage II pressure ulcer that worsened and required two surgical interventions due to delayed identification and treatment. The facility also had other cases of facility-acquired pressure ulcers and had no tracking system in place to monitor skin issues or pressure ulcer progression, despite this being a repeat deficiency. Additionally, the facility's QAPI meetings did not consistently address critical issues such as pressure ulcers, as confirmed by both the Administrator and Medical Director, with no evidence of discussion or subcommittee meetings on these topics since the previous year. The facility also failed to monitor and track mandatory staff training in key areas, including communication, resident rights, abuse, neglect, QAPI, infection control, compliance, and behavioral health. Medication administration audits revealed that approximately 50 residents experienced late or missed medications, with about 2,900 instances of late or missed doses and 15 significant medication errors. These deficiencies were identified during a recertification survey, which also found multiple repeat deficiencies and cited the facility at the immediate jeopardy level for QAPI non-compliance.