Failure to Conduct QAPI Review After Resident Death and Alleged Neglect
Penalty
Summary
The facility failed to conduct a Quality Assurance and Performance Improvement (QAPI) meeting after allegations of neglect and concerns were identified regarding the death of a resident. The resident was found unresponsive just after midnight, and staff initiated CPR before transferring the resident to the hospital. Hospital and EMS records indicated the resident exhibited signs of rigor mortis and a low core body temperature, suggesting the resident had been deceased for some time prior to being found. There were inconsistencies in staff witness statements, documentation, and timelines regarding when the resident was last cared for and when CPR was initiated. The Nursing Home Administrator (NHA) acknowledged responsibility for monthly QAPI meetings and stated that incidents such as neglect and abuse were typically brought to these meetings. However, the NHA did not bring this incident to QAPI, citing no concerns with staff performance during the code blue event. The Medical Director and DON were aware of the circumstances and documentation discrepancies, including a CNA's false documentation that the resident was not in the facility during the relevant shift. Despite being aware of an allegation of neglect, the facility did not address the incident through the QAPI process.