Failure to Maintain Effective QAPI Program and Ensure Timely Pain Management
Penalty
Summary
The facility failed to maintain an ongoing, effective QAPI program that systematically identified, reported, investigated, analyzed, and prevented adverse events, as well as documented the development, implementation, and evaluation of corrective actions or performance improvement activities. Specifically, the facility did not recognize or appropriately respond to a decline in a resident's change in condition and did not consistently provide pain management or ensure that pain medication was ordered and available upon admission for another resident. These failures were identified through record review, interviews, and document review, and resulted in serious harm to two residents. One resident with myelodysplastic syndrome, anemia, and acute congestive heart failure was admitted with a high cognitive status. The facility did not notify the physician of the resident's refusal to have an immediate laboratory test, failed to obtain a urine culture and sensitivity test as ordered, did not monitor the resident after reports of ongoing nausea, decreased appetite, and diarrhea, and failed to act upon a critically high white blood cell count. Documentation and communication regarding the resident's change in condition were lacking, and there was insufficient follow-up and monitoring after significant symptoms and abnormal lab results were reported. Another resident admitted with pancreatic adenocarcinoma and other serious conditions had orders for Dilaudid for pain management, but the facility failed to consistently provide the medication as ordered. The pharmacy did not receive the written script for Dilaudid until several days after admission, resulting in the resident experiencing pain levels up to 10 out of 10. The DON was not aware of the medication's unavailability, and nursing staff did not follow up with the pharmacy when the medication was not delivered. This failure led to the resident not receiving adequate pain management during their stay.