Failure of QAPI Program to Identify Systemic Issues in ADLs, Care Planning, and Environment
Penalty
Summary
The deficiency involves the facility’s failure to operate an effective QAPI/QAA program that identifies and addresses failed systems. During an interview, the Administrator stated that the QAPI committee relied on data from the 5-star report, Resident Council meetings, grievances, families, residents, and the IDT, and that current focus areas included falls, pressure ulcers, and transcription errors. However, during the survey, three additional system failures were identified by surveyors—Activities of Daily Living (ADLs) related to showers/tub baths, ongoing review and revision of person-centered care plans, and maintaining a safe, clean, comfortable, and homelike environment—that had not been recognized or presented to the QAPI team by facility staff. Surveyors found that several dependent residents were not receiving regular full-body baths, specifically showers or tub baths, and observations revealed residents with oily hair, scaly skin, and body odor, with some residents reporting not receiving showers or hair washing. Review of shower/tub bath documentation confirmed that residents were not receiving regular full-body bathing. Review of person-centered care plans for all sampled residents showed a pattern of plans not being reviewed and revised on an ongoing basis as residents’ conditions improved or deteriorated. Environmental observations identified resident rooms that were not safe, clean, comfortable, or homelike, including one room with ongoing heating issues where a resident reported being cold on several nights, and more than 15 rooms with walls needing painting or with torn wallpaper and exposed wallboards. These issues were not identified by the facility’s QAPI process, and when given an opportunity, the leadership team did not provide additional information to demonstrate that these system failures had been recognized or addressed through QAPI/QAA activities.
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