Failure to Identify and Address Elopement and Emergency Preparedness in QAPI Program
Penalty
Summary
The facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) program to identify and address compliance concerns, specifically related to accident and hazard prevention. The QAPI committee did not identify or address issues involving resident elopement and emergency preparedness, including the lack of supervision necessary to prevent a resident from leaving the facility unsupervised and the absence of a system to ensure staff followed emergency evacuation procedures. These deficiencies resulted in situations that rose to the level of immediate jeopardy, where a serious adverse outcome was likely. Record review revealed that the facility had a history of similar deficiencies, with previous citations for failure to prevent accidents and hazards, including falls and elopement. Despite having a QAPI policy and procedure in place, the committee did not recognize or prioritize these high-risk areas for process improvement. The facility's QAPI meetings focused on standard issues such as falls, infections, and hospitalizations, but did not address elopement or emergency egress concerns until after they were identified by surveyors. Interviews with facility leadership, including the medical director, NHA, and DON, confirmed that the QAPI committee met regularly and included required members, but had not previously identified elopement or emergency preparedness as areas needing attention. The medical director had not provided recent education to staff or reviewed policies related to these issues. The lack of systematic identification and prioritization of these high-risk concerns contributed to the facility's failure to prevent immediate jeopardy situations related to resident safety.