Failure to Address Reportable Incidents in QAPI Committee
Penalty
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) committee developed and implemented appropriate plans of action to address identified quality of care deficiencies. Specifically, there was no documented evidence that the QAPI committee convened to discuss, develop, or prioritize actionable plans for two reportable incidents involving residents. One incident involved a resident with Alzheimer's disease, Parkinsonism, and Bipolar Disorder who was barricaded in their room by a Certified Nurse Aide, with the resident being found approximately three hours later by a housekeeper. Another incident involved a resident with Dementia, Cerebral Infarction, and Peripheral Vascular Disease who was videorecorded by staff while washing their briefs, and the video was posted on social media by a Certified Nurse Aide. Review of the facility's QAPI meeting agendas over several months revealed that neither incident was discussed, and there were no documented action plans to address these events. Although the facility's policy emphasized proactive identification and resolution of performance issues to enhance resident safety and quality of care, the QAPI committee did not address these specific incidents as required. The lack of documented discussion and action plans in the QAPI meetings constituted a failure to follow the facility's own quality improvement procedures.