Failure to Sustain Effective QAPI Program and Address Repeated Deficiencies
Penalty
Summary
The facility failed to ensure its Quality Assessment and Performance Improvement (QAPI) program effectively self-identified deficiencies and developed or implemented effective plans of action to sustain corrections for previously cited deficiencies. Despite having a policy stating that QAPI would oversee the identification and correction of quality issues, the facility did not consistently recognize or address ongoing problems. During interviews, the Administrator was unaware of several issues found during the survey, including deficiencies in the restorative nursing program, nutrition management related to fluid restrictions and inaccurate documentation, and pain management practices involving non-pharmacological interventions. The Administrator acknowledged awareness of staffing issues related to long call light wait times but only initiated a Performance Improvement Plan after several months of related grievances, indicating a delay in addressing known concerns. Repeated citations were noted for areas such as range of motion/mobility, nutrition/hydration status, and sufficient nursing staff, with deficiencies recurring over multiple years. Review of QAPI documentation showed that while meetings were held, the facility did not self-identify deficiencies, recognize failures to sustain previous corrections, or make timely revisions to action plans. This lack of effective QAPI oversight led to a pattern of deficiencies that were not adequately addressed or corrected, as evidenced by repeated citations in the same areas.