Failure to Implement Effective QAPI Plan for Falls
Penalty
Summary
The facility failed to ensure that its Quality Assurance Performance Improvement (QAPI) program effectively implemented a plan to address quality deficiencies related to falls. Documentation from QAPI meetings over several months showed that falls were reviewed, and in one month, 25 falls involving 22 residents were recorded, with two residents accounting for five of those falls. However, there was no evidence in the facility's records of corrective actions being developed or implemented to address the high number of falls, nor was there documentation of a good faith effort to resolve the issue. Interviews with nursing staff revealed that they had not been involved in QAPI meetings or performance improvement projects, and their input on fall prevention was not solicited in a structured manner. Further interviews with the Director of Nursing (DON) and the Administrator indicated that while falls were discussed in meetings and some interventions, such as increased rounds, were verbally communicated, there was no written action plan or systematic tracking of interventions and their effectiveness. The DON expected a written plan with measurable goals and tools to assess outcomes, but was not involved in follow-up or action items. The Administrator acknowledged that interventions were discussed verbally and corrections were made on an individual basis, but there was no formal, documented plan to address the ongoing issue of falls.