F0867

F

Failure of QAPI Committee to Analyze and Address Increased Falls and Falls With Major Injury

Minneapolis, Minnesota Survey Completed on 01-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement its Quality Assurance and Performance Improvement (QAPI) program in accordance with its written plan, specifically related to identifying, analyzing, and responding to increased resident falls and falls with major injury. The facility’s QAPI Plan requires the QAA committee to review data monthly, identify high-risk and problem-prone areas, initiate Performance Improvement Projects (PIPs), conduct root cause analyses, and develop system-level corrective actions. Facility records, Quality Review minutes, QAPI documentation, and incident reports showed that falls, including falls with major injury, triggered internal quality measures in multiple quarters, but the QAPI documentation did not show initiation of sustained PIPs, completion of comprehensive root cause analyses, or implementation and monitoring of system-wide corrective actions related to falls.

Quality Review documentation over several months showed that the facility tracked fall rates per 1,000 resident days with a stated goal of 5, and repeatedly recorded fall rates above this goal. For example, fall rates and counts included: March (4.2; 9 falls), April (15.1; 31 falls), May (5.9; 12 falls), June (9.0; 17 falls), July (3.1; 6 falls), August (8.5; 17 falls), September (8.3; 16 falls), October (6.1; 13 falls), and November (5.7; 12 falls month-to-date in mid-November, with 23 total falls for the month). The documentation consistently included data tables and graphs showing cumulative fall totals, with a high proportion of unwitnessed falls and a concentration of falls in resident rooms and bathrooms. Despite increases in cumulative falls between reporting periods and repeated exceedance of the facility’s fall rate goal, the Quality Review minutes did not reflect discussion of underlying or contributing factors, completion of comprehensive root cause analyses, initiation of PIPs, or development and monitoring of system-wide corrective actions related to fall prevention.

The deficiency is further supported by specific fall events and harm identified in a related fall management citation (F689), which documented that the facility failed to implement a fall management program including care plans, comprehensive fall analysis, and appropriate interventions for five residents at risk for falls. These residents experienced multiple unwitnessed falls, including one resident with four unwitnessed falls and a left tibial fracture requiring hospitalization, and another resident with an unwitnessed fall resulting in a spinal fracture and hospitalization. Quality Review documentation identified at least two residents with falls resulting in major injury, but one major injury was not reflected in the November Quality Review minutes because the facility became aware of it after the report was generated, and it was still not accounted for in the subsequent quality meeting minutes. Interviews with the DON, regional director of clinical services, and medical director confirmed that, despite recognition of high fall rates and metric triggers, concerns about increased falls were not brought to the QAPI committee, and the medical director was not informed of any concern with an increase in falls.