Failure of QAPI Process to Address Falls, Med Errors, and Pressure Ulcers
Penalty
Summary
The facility failed to ensure its QAPI committee identified, investigated, analyzed, and responded to high-risk issues related to falls, medication errors, and pressure ulcers, despite consistently collecting data on these events. From May 2025 through January 2026, the facility tracked numbers of falls, pressure ulcers, and medication errors each month, but the documentation did not include root cause analyses, prioritization of high-risk or recurring issues, development of performance improvement projects, implementation of corrective actions, or monitoring of interventions for effectiveness. QAPI records for these months showed counts of falls, pressure ulcers of various stages, and medication errors, but repeatedly noted no documented discussion or action plans, and often lacked information on whether pressure ulcers were facility-acquired or present on admission. The deficiency was further evidenced by specific care failures cited under related tags. For falls and safety, staff used the wrong size harness for a sit-to-stand mechanical lift transfer for one resident after that resident had previously fallen from a sit-to-stand lift and sustained minor injuries. The facility also failed to comprehensively investigate and analyze falls for root cause and to implement appropriate interventions to prevent or reduce the risk of future falls for another resident. For medication administration, one resident experienced a significant medication error when staff did not observe the rights of medication administration and gave the resident another resident’s medication, resulting in the resident becoming unresponsive, requiring hospitalization for hypotension, and developing an acute kidney injury. For pressure ulcer care, the facility failed to monitor, comprehensively assess, and develop and implement individualized interventions to prevent or mitigate the risk of pressure ulcers and prevent deterioration for three residents reviewed for pressure ulcers. One of these residents developed a Stage 2 sacral pressure ulcer that deteriorated to a Stage 3 ulcer. Interviews with the medical director and the administrator confirmed that, although the QAPI committee met monthly and reviewed data on wounds, falls, and medication errors, there were no current action plans addressing these issues, no minutes documenting discussions over the last four quarters, and no evidence that adverse outcomes were being analyzed and acted upon as outlined in the facility’s own written QAA/QAPI plan.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.