Failure to Implement Effective QAPI Program for Medication Administration
Penalty
Summary
The facility's quality assurance committee failed to effectively implement its QAPI program aimed at reducing medication errors and preventing late medication administration. Despite having a QAPI project in place, the committee did not fully implement the interventions, did not adequately investigate the causes of late medication administration and errors, and failed to monitor or reassess the program when issues persisted. This resulted in continued medication errors and late administration for five of eight sampled residents, with the potential to affect all residents in the facility. Specific incidents included a nurse administering 12 medications late to a resident with epilepsy, including a seizure medication, and another nurse administering a dose of methadone five times higher than ordered to a resident with acute heart failure and dementia. Additional cases involved late administration of blood pressure and anticoagulant medications to residents with significant cardiovascular and neurological conditions, as well as late administration of pain medications to a resident with chronic pain syndrome. Observations and interviews revealed that nurses were often delayed due to high workloads, lack of assistance, and frequent distractions, with some nurses admitting to documenting medications as given on time even when they were late. Record reviews showed that the facility's QAPI program relied on self-reporting of errors by nursing staff and limited audits by the DON, which were not consistently performed as outlined in the program. The pharmacy consultant was not fully integrated into the QAPI process and was unaware of recent medication errors or related QAPI plans. The facility's policy required ongoing evaluation and monitoring of the QAPI program, but these steps were not adequately carried out, contributing to the persistence of medication administration issues.