F0867

L

Failure to Use QAPI and Adverse Event Data to Prevent Repeat Serious Fall Injuries

Jacksonville, Florida Survey Completed on 12-10-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to operate an effective QAPI process that used adverse incident data to conduct root cause analyses and develop timely, effective performance improvement activities after serious resident injuries. The facility’s written QAPI policy stated that the program would encompass all segments of care and services, track and investigate adverse events every time they occur, and use a systematic approach to identify gaps or patterns in care, prioritize high‑risk or problem‑prone issues, and determine which problems would become performance improvement projects (PIPs). Despite this, the QAPI committee did not meet or become involved after two serious fall incidents involving residents, and no PIPs were developed in response to those events. The Administrator, who served as QAPI chair, confirmed that the QA committee had not been involved with either incident and that RCAs and corrective actions were being handled outside the formal QAPI structure.

One resident, admitted for aftercare following joint replacement surgery with additional diagnoses including osteoporosis, muscle weakness, presence of a right artificial hip joint, and unsteadiness on feet, was actively being prepared for discharge with goals of walking safely and being independent. Her orthopedic physician had ordered weight bearing as tolerated to the right lower extremity with a hinged knee brace locked in extension for all weight bearing, and an ARNP entered the brace order into the electronic record. However, the brace requirement was not added to the resident’s OT and PT precautions until nine days after she fell. During an OT session practicing a laundry task with a COTA, the resident was filling a basket attached to her walker when the basket started to fall; as the COTA attempted to adjust it, the resident lost her balance and fell. She was not wearing the ordered hinged knee brace locked in extension at the time of the fall and sustained a nondisplaced fracture of the proximal tibia/fibula, a tear of the medial meniscus, hemarthrosis, and associated pain and fear of using the right leg. Although an RCA was discussed informally by the interdisciplinary team, the QAPI committee did not conduct the RCA or initiate a formal PIP.

A second resident, admitted with diagnoses including an unspecified right femur fracture, prior fall on the same level, malignant neoplasm of the lung with secondary brain neoplasm, long‑term anticoagulant use, history of TIAs, and severe protein‑calorie malnutrition, had been assessed as a high fall risk and had an active physician’s order for a fall risk protocol with frequent rounding and safety checks. Her care plan identified risk for falls and injury related to medical conditions and documented a prior fall with family present. Despite these identified risks and orders, a PTA transferred the resident to the toilet, placed the call light across her lap, instructed her to pull it when finished, and then left the room without notifying nursing staff or a CNA that the resident was on the toilet. The PTA did not see the sign on the door indicating fall risk. The resident was later found on the bathroom floor with a scalp hematoma and ear injuries and was sent to the hospital, where a CT scan showed a subarachnoid hemorrhage in the right posterior temporal lobe. The QAPI committee did not meet after this incident, did not conduct the RCA, and did not develop a PIP, even though the facility’s own policy required systematic review of adverse events and prioritization of high‑risk, high‑frequency, or problem‑prone issues for performance improvement.

Interviews with facility leadership and the risk manager confirmed that RCAs and corrective actions were being handled through informal meetings and daily clinical discussions rather than through the formal QAPI committee structure described in the facility’s policy. The risk manager stated that when incidents with potential for injury occurred, she convened RCA meetings with selected staff within 24–48 hours, separate from QAPI meetings, and that the QAPI/QA committee was not involved in these post‑incident efforts. She also stated that the QA committee primarily reviewed PIPs after they were already developed and did not participate in PIP development or provide substantive input, and that no PIPs were created in response to the two fall incidents. The Administrator and Medical Director acknowledged that the QAPI process was not being followed as intended, and that the governing body was aware that RCAs and PIPs were being created without QA committee involvement. Immediate Jeopardy at scope and severity level L was identified, with the report stating that the failure to develop measures needed to ensure the safety and protection of other residents had the potential to affect all 97 residents should an injury incident occur.