Failure to Implement Effective QAPI Program Following Fire Incident
Penalty
Summary
Facility staff failed to implement an effective QAPI (Quality Assurance and Performance Improvement) program related to a fire incident involving residents. On the date of the incident, a resident lit a roll of toilet paper on fire in his bathroom, which was extinguished by staff. Both residents in the affected room were evacuated, and the fire department responded. The resident responsible for the fire had a known history of attempting to use a lighter in the room and was placed on one-on-one supervision until cleared by psych evaluation. Assessments for pain, skin, and respiratory status were conducted for both residents involved. Despite the QAPI plan outlining steps to prevent recurrence, including the use of lock boxes for smoking materials and staff education, the facility failed to ensure these measures were effectively implemented. During interviews, a resident who smoked stated she did not use a lock box and hid her belongings in her room, with a lock box found open and unsecured. Multiple staff members, including CNAs, LPNs, and a housekeeper, reported not receiving education or instructions regarding the fire incident, interventions for the resident involved, or the need to inspect rooms for lighters and smoking paraphernalia. The administrator acknowledged not noticing the ineffectiveness of the QAPI plan. The facility's policy assigns responsibility to the administrator for directing the QAPI plan to identify and address risks or deficiencies, but the documented actions and staff interviews indicate a lack of follow-through and communication regarding the interventions required to prevent similar incidents.