Ineffective QAPI Program Fails to Address Abuse and Dementia Care Concerns
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program capable of identifying and addressing compliance concerns related to abuse, neglect, and dementia care. The facility’s written QAPI policy required establishment and implementation of a Quality Assessment and Assurance Committee, development of a written QAPI plan reviewed and updated annually, and implementation of data-driven Performance Improvement Projects (PIPs). However, surveyors found that the QAPI committee did not identify or address issues associated with abuse, neglect, and dementia care, despite existing concerns in these areas. Cross-referenced deficiencies included failures to ensure residents were free from abuse and failures to provide appropriate dementia care to help residents attain or maintain their highest level of functioning. Record review and staff interviews further showed that the facility did not have a QAPI PIP plan in place for the secure memory care unit, even though residents in that unit were able to wander from room to room, resulting in resident-to-resident physical abuse. The NHA and DON acknowledged that, at the time of the survey, there was no active PIP specific to the secure memory unit and that staff had not received needed education related to abuse and dementia. Although the DON stated the facility was working on several PIPs, including falls and dementia training, they were unable to provide specific details about these projects, demonstrating that the QAPI process was not effectively organized or implemented to address the identified concerns.
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