Failure to Implement Effective QAPI Program for Falls
Penalty
Summary
The facility failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) program was developed, implemented, and maintained in a comprehensive manner specifically for falls. Record review showed that the facility's QAPI policy required a systematic, data-driven approach to quality management, but there was no documentation of ongoing QAPI activities related to falls. Incident logs for three consecutive months revealed multiple fall incidents, including several with injuries, yet there was no evidence that these incidents were systematically addressed through the QAPI process. Further review of the Quality Assessment and Improvement Committee Summary indicated that no effective QAPI program was in place for falls. During interviews, both the Administrator and the DON confirmed the absence of documentation or evidence of an effective QAPI program addressing falls, and the Administrator acknowledged that the facility's QAPI program was not up to standard. This deficiency had the potential to affect all 85 residents residing in the facility.