Repeated Deficiency in Medical Record Documentation Due to Inadequate QAPI Oversight
Penalty
Summary
The facility failed to implement its Quality Assurance and Performance Improvement (QAPI) policies to ensure thorough monitoring and tracking of previously identified areas of concern, specifically regarding the accuracy of medical record documentation. Despite having a QAPI program with objectives to monitor and evaluate corrective actions, the facility had repeated deficiencies at F842, related to medical record accuracy, identified during complaint surveys. The review of documentation showed that education was provided to nursing staff and audits were planned, but the same deficiency was cited again in subsequent surveys, indicating that the measures taken were not effectively monitored or sustained. During interviews, the Administrator reported limited participation in QAPI meetings since starting at the facility and was unaware of the previous deficiencies related to medical records documentation. The repeated citation of F842 demonstrated insufficient auditing and oversight by the QAPI team, as the facility did not ensure that prior improvement measures were realized and maintained, leading to ongoing non-compliance with documentation standards.