Failure to Implement Effective QAPI Program and Address Dementia Care Deficiencies
Penalty
Summary
The facility failed to ensure its Quality Assurance and Performance Improvement (QAPI) program effectively identified and corrected quality deficiencies, particularly in the dementia care unit. Interviews and record reviews revealed that the QAPI committee did not consistently review or analyze data, nor did it develop plans of action when concerns were identified. The QAPI plan document was incomplete, lacking essential information such as the facility name, vision, mission, and purpose. The Nursing Home Administrator, who served as the QAPI Coordinator, acknowledged that records of ongoing data review and analysis were limited, and necessary reports were not being generated due to significant management turnover. As a result, issues such as the use of psychotropic medications and staff training deficiencies were not adequately monitored or addressed. A resident with dementia did not receive individualized care despite interventions provided by her Durable Power of Attorney (DPOA) to reduce stress responses. Staff interviews indicated a lack of knowledge regarding effective interventions for this resident, and concerns raised by staff were not acted upon. The QAPI committee was aware of deficiencies in staff performance evaluations and training but did not implement a Performance Improvement Plan (PIP). The facility was unaware of non-compliance related to psychotropic medication use until it was identified during the survey.