Failure to Integrate Pharmacy and Controlled Substance Issues into QAPI
Penalty
Summary
The facility failed to develop, implement, and maintain an effective, comprehensive QAPI system that addressed adverse events and pharmacy-related issues, including controlled substances and wasted medications. The facility’s QAPI policy stated that the QAPI committee was responsible for implementing and maintaining an ongoing systemwide process of quality improvement. However, the Director of Health Information Management (HIM) reported that although the QAPI committee met monthly and had recently held an emergency meeting related to a resident fall, she did not recall controlled substances being discussed in QAPI and was not aware of pharmacy issues identified in October and November 2025 and January 2026. She stated the current performance improvement plan focused on Medicare certification and inventory sheets, not on the pharmacy concerns cited by surveyors. The DON stated that medication concerns were never brought to QAPI meetings and that an internal audit involving extra narcotic sheets had been a concern, but those checks were not documented. She indicated that topics typically brought to QAPI included mealtime delivery, falls, and pressure ulcers, and that medication issues would only be sent to QAPI if not addressed by nursing. The Administrator acknowledged that wasted medication was a concern but stated the facility did not track wasted medications and that wasted medication issues, which she believed should have been brought to QAPI and to the Medical Director, were not addressed there. She described medication errors as wrong medications given or controlled substances pulled and not documented in the eMAR. The Medical Director reported he had not been informed of pharmacy audit concerns from October and November 2025 and stated he would want to know about discrepancies affecting his residents and believed such issues should be brought to QAPI to determine root causes and corrective actions.
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