Failure to Maintain Effective QAPI Program and Investigate Medication and Transportation Issues
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program, as evidenced by incomplete documentation, lack of follow-through on action steps, and insufficient investigation into significant resident care issues. QAPI meeting minutes did not include attendance records, and there was no evidence that required weekly meetings between the administrator and transportation aide occurred to resolve transportation issues. The governing body was not involved in QAPI meetings, and regional leadership was unaware of critical care failures identified by surveyors. One resident developed osteomyelitis of the foot after the facility failed to provide physician-ordered medication following a stent procedure and did not arrange necessary cot transportation for follow-up appointments. The facility lost its contract with a non-emergent ambulance transportation service and did not secure a replacement, resulting in missed medical appointments for residents requiring cot transport. The administrator was unable to identify which or how many residents missed appointments during this period. Additionally, the facility did not thoroughly investigate allegations of missing narcotics, resulting in unaccounted controlled substances for multiple residents. Documentation for controlled substance administration and inventory was missing, and staff failed to follow required procedures for signing in and out medications. Despite reports and evidence of missing medications, the facility did not determine the extent of the issue or conclude its investigation, and education was provided to nursing staff without a comprehensive review of the problem.