Failure to Use QAPI to Identify and Address Pressure Ulcer Care Issues
Penalty
Summary
The facility failed to implement and maintain a comprehensive Quality Assurance Performance Improvement (QAPI) program and plan to address care issues and concerns, particularly related to pressure ulcer care. Review of Quality Assurance (QA) committee attendance records for the previous eight months showed that QA meetings were held monthly and included discussion of falls, pressure ulcers (healing, not healing, present on admission, and in-house acquired), antibiotic use, and weight loss. However, the annual survey identified noncompliance in pressure ulcer care, including prevention and treatment, which resulted in substandard quality of care. This noncompliance led to an Immediate Jeopardy situation for one resident beginning on 08/27/25 and Actual Harm for another resident beginning on 01/12/26. During interviews, the Administrator stated that QAPI meetings were held monthly and confirmed attendance at the December 2025 and January 2026 meetings, during which no residents were identified as having ongoing issues or care needs related to pressure ulcers. The Administrator further reported that, upon review, there had been no identification of ongoing issues and care for pressure ulcers in the six months of QAPI meetings prior to his tenure (May 2025 through November 2025). This was inconsistent with the facility’s written QAPI policy, dated November 2025, which described QA as a continuous process in which the QA Committee is responsible for reviewing resident care and service trends, identifying quality issues, and developing plans of action, including review of pressure ulcer care trends based on data collection.
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