Repeated QAPI Failures in Quality of Care, Pharmacy, Nutrition, and Infection Control
Penalty
Summary
Facility staff failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) Program, as evidenced by repeated deficiencies in multiple areas including Quality of Care, Pharmacy Services, Food and Nutrition Services, and Infection Control. These deficiencies were identified through staff interviews, clinical record reviews, and facility document reviews, and were noted to have recurred across several standard and abbreviated surveys over a period of several years. Specifically, staff did not consistently follow medical provider orders for a significant number of sampled residents, did not ensure that provider-ordered medications were available and administered as ordered, and allowed expired food items to remain in use. Additionally, staff failed to adhere to established infection control guidelines. The report details that the same areas of deficiency were cited in previous surveys, indicating a lack of effective monitoring and revision of plans of correction. For example, failures to follow medical provider orders and ensure medication availability were cited in both past and current surveys, as was the presence of expired food and lapses in infection control practices. Despite the facility having a policy outlining a systemic approach to performance improvement, there was no evidence provided to the survey team that demonstrated effective tracking or sustained improvement in these areas prior to the exit conference.