Failure to Use QAPI After Delayed Sepsis Response
Summary
The deficiency involves the facility’s failure to implement an effective QAPI process following a serious clinical incident involving a resident who exhibited signs and symptoms of sepsis and was not transferred to the hospital in a timely manner. On 9/1/24 at 6:27 a.m., the weekend on-call licensed provider was notified that the resident’s blood pressure was 84/49, and orders were given to hold aspirin and antihypertensive medications, check for blood in the stool, and perform hourly blood pressure checks. By 7:30 a.m., the resident’s blood pressure had decreased to 80/41, oxygen saturation was 84% on room air, and the resident was unresponsive to verbal stimuli; the resident’s neurological status of being unresponsive did not change throughout the day. The primary care physician (PCP) was notified and ordered IV fluids at 100 ml/hr. At 8:00 a.m., the resident’s blood pressure was 82/38 and oxygen saturation was 93% on 4 L O2. At 9:30 a.m., the PCP ordered additional IV fluids. At 10:00 a.m., the resident’s blood pressure was 85/43, heart rate was 132, and oxygen saturation was 85–90% on 5 L O2, with IV fluids continuing. At 11:08 a.m., blood pressure was 79/40 and oxygen saturation was 99% on 8 L O2, and at 12:00 noon, blood pressure was 81/41. The PCP then ordered transfer to the hospital. EMS records show the facility called for emergency assistance at 12:23 p.m., with EMS documenting a primary impression of sepsis and hypotension as the primary sign/symptom. The resident’s death certificate listed time of death at the hospital as 3:37 p.m. and sepsis as the cause of death. During an interview on 4/8/26, the DON stated that recognizing early signs and symptoms of sepsis and taking immediate action is a nursing standard in the facility and acknowledged it would be very hard to say the resident was transferred in a timely manner. The DON reported she could not find specific evidence that the sequence of events surrounding the resident’s discharge was reviewed by the QAPI committee or that a quality improvement plan was considered after the delay in treatment. She stated that weekly risk management meetings, considered part of the QAPI process and used to discuss all discharges from the previous week, had no documented evidence of review of this resident’s case, and she was not aware of any action plan developed regarding the situation. Review of the facility’s QAPI policy showed that the Administrator is responsible for directing and implementing a QAPI plan that systematically identifies actual or potential areas of risk or deficiency and targets high-risk, high-volume, or problem-prone processes, but there was no documentation that this incident was addressed through that process.
Penalty
Resources
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The facility did not effectively use its QAPI program to identify and address ongoing issues in pressure ulcer prevention and treatment, despite holding monthly QA meetings that were supposed to review trends such as falls, pressure ulcers, antibiotic use, and weight loss. The Administrator confirmed that in multiple consecutive months no residents with ongoing pressure ulcer issues were identified or discussed, even though survey findings later showed noncompliance in pressure ulcer care that resulted in substandard quality of care, including Immediate Jeopardy for a resident and Actual Harm for another. This practice conflicted with the facility’s own QAPI policy, which required continuous review of resident care trends and targeted performance improvement, including pressure ulcer care.
The facility failed to maintain an effective QAPI program, with incomplete documentation and lack of follow-through on action steps. Residents missed critical medical appointments due to unresolved transportation issues, and there was insufficient investigation into missing narcotics, with missing documentation and unaccounted controlled substances. Leadership was unaware of these significant care failures.
The facility did not self-identify any improvement opportunities for the first three quarters of 2024, affecting all 64 residents. QAPI meetings in January, April, and July were identical, with no new areas identified. Interviews with the Administrator and DON revealed a lack of proactive measures, focusing only on past citations without recording meeting notes or taking action to prevent recurring issues.
The facility failed to implement a comprehensive QAPI program, affecting all 50 residents. Multiple citations were noted in areas such as nursing services and quality of care. The Administrator could not provide evidence of quarterly meetings or monitoring of corrective actions. The facility's QAPI policy goals were not met.
The facility failed to address repeated concerns in kitchen and dining services, as observed in multiple surveys resulting in citations. Despite having corrective action plans, the facility did not monitor quality assurance issues and did not educate new kitchen staff on previously cited deficiencies. Observations revealed non-compliance with recipe adherence, food palatability, storage, and kitchen cleanliness.
The facility failed to address deficiencies in resident care and staffing, affecting all 105 residents. Surveys identified issues in daily living assistance, wound care, accident prevention, and more, leading to Immediate Jeopardy. The QAPI program lacked documentation of corrective efforts, and staff interviews revealed a lack of involvement in addressing these concerns.
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.
Failure to Maintain Effective QAPI Program and Investigate Medication and Transportation Issues
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program, as evidenced by incomplete documentation, lack of follow-through on action steps, and insufficient investigation into significant resident care issues. QAPI meeting minutes did not include attendance records, and there was no evidence that required weekly meetings between the administrator and transportation aide occurred to resolve transportation issues. The governing body was not involved in QAPI meetings, and regional leadership was unaware of critical care failures identified by surveyors. One resident developed osteomyelitis of the foot after the facility failed to provide physician-ordered medication following a stent procedure and did not arrange necessary cot transportation for follow-up appointments. The facility lost its contract with a non-emergent ambulance transportation service and did not secure a replacement, resulting in missed medical appointments for residents requiring cot transport. The administrator was unable to identify which or how many residents missed appointments during this period. Additionally, the facility did not thoroughly investigate allegations of missing narcotics, resulting in unaccounted controlled substances for multiple residents. Documentation for controlled substance administration and inventory was missing, and staff failed to follow required procedures for signing in and out medications. Despite reports and evidence of missing medications, the facility did not determine the extent of the issue or conclude its investigation, and education was provided to nursing staff without a comprehensive review of the problem.
Failure to Self-Identify Improvement Opportunities
Penalty
Summary
The facility failed to self-identify any areas of opportunities for improvement for the first three quarters of 2024, potentially affecting all 64 residents. The Quality Assurance Performance Improvement (QAPI) Plan meeting was held on January 17, 2024, where recent survey results were reviewed, and plans were made to monitor various audits, including Pre-Admission Screening and Resident Review results, baseline care plans, comprehensive care plans, fall audits, catheter care audits, diet audits, oxygen audits, personal protection equipment audits, pneumonia vaccine audits, and COVID-19 testing per CDC guidelines. A new Performance Improvement Plan was initiated for wound care. However, the QAPI meetings held on April 23, 2024, and July 30, 2024, were identical to the January meeting, with no new areas identified for improvement. Interviews with the Administrator and the Director of Nursing (DON) revealed that the facility had not attempted to self-identify any opportunities for improvement and had only focused on addressing the citation issued at the last annual survey. The Administrator admitted that no notes were recorded for the meetings, and there was no true course of action taken to prevent the recurrence of the same concerns identified. The facility's policy on Quality Assurance Performance Improvement Plan stated that the program should be data-driven and utilize a proactive approach to improve quality of care and services, but this was not reflected in the facility's actions.
Failure to Implement Comprehensive QAPI Program
Penalty
Summary
The facility failed to establish a comprehensive Quality Assurance and Performance Improvement (QAPI) program that effectively evaluated areas in need of improvement and monitored the effectiveness of corrective actions. This deficiency affected all 50 residents in the facility. The facility's survey history revealed multiple citations in areas such as nursing services, quality of care, admission discharge and transfer, freedom from abuse neglect and exploitation, and food and nutrition services. Despite submitting plans of corrections, there was no evidence that these were reviewed or further interventions were implemented by the QAPI committee. An interview with the facility's Administrator revealed that there was no documentation of a comprehensive QAPI program being implemented since the last annual survey. The Administrator could not provide evidence of quarterly meetings or that the committee had thoroughly evaluated and identified areas needing improvement. Additionally, there was no documentation showing that prior deficient practices were being monitored to ensure the plan of correction was implemented and sustained. The facility's undated QAPI policy outlined the goals and responsibilities of the QAPI Committee, but there was no evidence these were being met.
Deficiency in Kitchen and Dining Services
Penalty
Summary
The facility failed to address concerns in a timely manner and did not ensure their Quality Assurance and Performance Improvement (QAPI) program committee thoroughly evaluated and identified areas in need of improvement. This deficiency was observed through a series of surveys, including an annual survey and multiple complaint surveys, all of which resulted in citations related to kitchen and dining services. Despite having approved corrective action plans in place, the facility did not monitor for quality assurance issues related to these services, except for dietary preferences, and failed to address repeated concerns raised in Resident Council meetings about food temperatures, condiments, portions, and variety. Interviews with the Administrator and Director of Nursing revealed that the facility had undergone a complete change in kitchen staffing, including the director, supervisor, and several cooks and aides, but there was no evidence that newly hired staff were educated on previously cited deficient practices. Observations during the annual survey indicated that the facility did not ensure recipes were followed, food was palatable, food was stored appropriately, and the kitchen was maintained in a clean and sanitary condition.
Removal Plan
- Ensuring staff were educated regarding appropriate kitchen and dining services
- Ensuring staff were educated on policies and procedures
- Conducting audits of resident meals
Facility Fails to Address Deficiencies in Resident Care and Staffing
Penalty
Summary
The facility failed to make good faith attempts to correct identified concerns as part of their Quality Assurance and Performance Improvement (QAPI) program, affecting all 105 residents. During the annual, extended, and complaint surveys, deficiencies were identified in areas such as activities of daily living assistance, wound care, range of motion needs, accident prevention, catheter care, nutritional needs, gastrostomy tube care, and pressure ulcer treatment. These deficiencies resulted in an Immediate Jeopardy situation. Additionally, the facility was found deficient in maintaining sufficient staffing levels, which also led to an Immediate Jeopardy. The review of the facility's QAPI program revealed a lack of documentation regarding efforts to address these deficiencies, including the absence of goals or measures to track improvement. Interviews with staff, including the RN MDS Coordinator and the Regional Clinical Nurse, highlighted a lack of involvement and action in addressing these concerns. The RN MDS Coordinator, who was asked to fill in as the Interim DON, had not participated in QAPI meetings or addressed concerns, as she was informed it was unnecessary. The Regional Clinical Nurse confirmed that staffing had been an ongoing concern since February 2024, with no documented attempts to increase staffing levels.
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