Failure of QAPI Program to Identify and Address Serious Quality of Care and Safety Issues
Penalty
Summary
The facility failed to maintain an effective, comprehensive, data‑driven QAPI program capable of identifying and addressing quality of care, quality of life, and resident safety concerns. Surveyors cross‑referenced multiple serious deficiencies that were not effectively captured or addressed through QAPI. These included a choking incident in which a resident on a minced and moist diet was served a regular meal, resulting in an actual choking episode that required multiple Heimlich attempts, as well as other residents being served incorrect diet textures during the survey. Additional cross‑referenced deficiencies involved two elopement incidents for a resident with wandering behaviors, where no new interventions were implemented after the first elopement and the resident later left the building without staff knowledge and was found locked outside. Another cross‑referenced deficiency involved a resident whose seizure medications were not administered as ordered on multiple occasions, including not being given at all on dialysis days, leading to increased seizures and multiple hospitalizations. The facility’s regulatory history showed repeat deficiencies that the QAPI program failed to prevent, including multiple citations for abuse prevention on the secure unit and repeated citations for significant medication errors, which escalated from potential for more than minimal harm to actual harm. The facility’s own QAPI policy required an effective, comprehensive, data‑driven program, but interviews revealed gaps in implementation. The MD reported being notified of the seizure medication error and expressed concern that seizure medications must be administered as ordered and that the neurologist should have been contacted for clarification. The NHA stated that abuse allegations were reviewed in QAPI and that he was aware of the significant seizure medication error but was unsure whether any performance improvement plans had been initiated. He also reported being aware of the choking incident but not aware that the kitchen was serving inappropriate diets, and he described the resident who eloped twice as someone for whom the facility was seeking a secured unit placement. These findings collectively demonstrated that the QAPI committee did not effectively identify, track, or address these serious and recurring quality of care and safety issues.
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