Failure to Analyze and Respond to Increased Resident Falls
Penalty
Summary
The facility failed to ensure its Quality Assurance and Performance Improvement (QAPI) committee effectively identified, investigated, analyzed, and responded to resident care issues, specifically regarding a high number of falls. Over several months, QAPI meeting minutes consistently documented falls as isolated incidents, with no trends identified, despite a significant increase in the number of falls in September. The committee did not comprehensively analyze the data or develop an action plan in response to the sudden rise in falls, and inaccuracies were noted in the documentation of fall incidents, including underreporting the number of falls and failing to identify multiple falls by the same resident. One resident experienced multiple falls since admission, culminating in a fall that resulted in a subarachnoid hemorrhage and hospitalization, which was classified as an immediate jeopardy event. The QAPI committee's meeting minutes did not reflect a thorough review or root cause analysis of the increased falls, nor did they document any systematic approach to identifying quality deficits in the fall management program. Although the medical director raised concerns and suggested forming an interdisciplinary team to address the issue, no formal action plan or investigation was initiated by the committee. Interviews with facility leadership confirmed that, despite recognizing a sharp increase in falls, the QAPI committee did not take steps to analyze or investigate the underlying causes. The facility's own policy outlines a systematic approach to performance improvement, including data analysis, root cause identification, and corrective action planning, but these processes were not followed in response to the increase in falls. As a result, the facility did not address the quality concern in a timely or effective manner.