§483.75(a) Quality assurance and performance improvement (QAPI) program.
Each LTC facility, including a facility that is part of a multiunit chain, must develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life. The facility must:
§483.75(a)(1) Maintain documentation and demonstrate evidence of its ongoing QAPI program that meets the requirements of this section. This may include but is not limited to systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events; and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities;
§483.75(a)(2) Present its QAPI plan to the State Survey Agency no later than 1 year after the promulgation of this regulation;
§483.75(a)(3) Present its QAPI plan to a State Survey Agency or Federal surveyor at each annual recertification survey and upon request during any other survey and to CMS upon request; and
§483.75(a)(4) Present documentation and evidence of its ongoing QAPI program's implementation and the facility's compliance with requirements to a State Survey Agency, Federal surveyor or CMS upon request.
§483.75(b) Program design and scope.
A facility must design its QAPI program to be ongoing, comprehensive, and to address the full range of care and services provided by the facility. It must:
§483.75(b)(1) Address all systems of care and management practices;
§483.75(b)(2) Include clinical care, quality of life, and resident choice;
§483.75(b)(3) Utilize the best available evidence to define and measure indicators of quality and facility goals that reflect processes of care and facility operations that have been shown to be predictive of desired outcomes for residents of a SNF or NF.
§483.75(b) (4) Reflect the complexities, unique care, and services that the facility provides.
§483.75(f) Governance and leadership.
The governing body and/or executive leadership (or organized group or individual who assumes full legal authority and responsibility for operation of the facility) is responsible and accountable for ensuring that:
§483.75(f)(1) An ongoing QAPI program is defined, implemented, and maintained and addresses identified priorities.
§483.75(f)(2) The QAPI program is sustained during transitions in leadership and staffing;
§483.75(f)(3) The QAPI program is adequately resourced, including ensuring staff time, equipment, and technical training as needed;
§483.75(f)(4) The QAPI program identifies and prioritizes problems and opportunities that reflect organizational process, functions, and services provided to residents based on performance indicator data, and resident and staff input, and other information.
§483.75(f)(5) Corrective actions address gaps in systems, and are evaluated for effectiveness; and
§483.75(f)(6) Clear expectations are set around safety, quality, rights, choice, and respect.
§483.75(h) Disclosure of information.
A State or the Secretary may not require disclosure of the records of such committee except in so far as such disclosure is related to the compliance of such committee with the requirements of this section.
§483.75(i) Sanctions.
Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions.
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Observations:
Based on review of select facility policy, clinical records, and incident reports and staff interviews, it was determined that the facility failed to demonstrate the implementation of ongoing QAPI programs, to include the use of systems for investigating and analyzing the root cause of adverse events, as evidenced by multiple falls incurred by one resident out of 18 sampled (Resident 65).
Findings include:
Review of the facility policy entitled "Quality assessment and improvement plan" last reviewed by the facility January 9, 2024 revealed that the facility is committed to incorporating the principles of Quality Assurance and performance Improvement (QAPI) into all aspects of the center work processes, services lines and departments. All staff and stakeholders are involved in QAPI to improve the quality of life and quality of care that out patients and residents experience.
The process included:
- The administrator directs the development and documentation of the center QAPI plan, including an annual QAPI calendar, and is responsible for development, maintenance and ongoing evaluation of an active and effective Quality Assurance Performance Improvement Committee.
-The committee meets at least 10 times annually, preferably monthly, to monitor quality within the center, identify issues and develop and implement appropriate plans of action to correct identified quality issues.
The responsibilities to include:
-Assess, evaluate and identify potential improvement opportunities based on:
-Current reviews of core systems
-all current regulatory on-site assessments
-Adverse events since the past meeting, including prevention opportunities, investigations and corrective actions.
A review of the clinical record revealed that Resident 65 was admitted to the facility on February 27, 2023, with diagnoses to include Parkinsons disease ( a progressive neurological disease), dementia, and a history of falling. The resident was placed on Hospice services November 24, 2023, for end stage Parkinsons disease.
The resident's baseline care plan, initiated February 27, 2023, revealed that Resident 65 had a history of falling prior to admission to the facility and impaired cognitive function related to Parkinson's disease and dementia with moderate, cognitive function. According to the resident's care plan the resident was at risk for falls related to his diagnosis of Dementia and Parkinson's disease. The resident's care plan indicated that the resident used a wheelchair for mobility and self-propelled throughout the facility as desired.
A quarterly minimum data set assessment (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated September 22, 2023, revealed the resident was moderately cognitively impaired, required staff assistance for activities of daily living and had a history of falling.
A review of incident reports revealed that Resident 65 fell while leaning forward in his wheelchair, on the following occassions:
-October 17, 2023, at 8:45 PM leaned foreward in his wheelchair and fell, sustaining a right forehead laceration
-November 1, 2023, at 1:45 AM leaned foreward in his wheelchair and fell, sustaining an abrasion on his left forehead
-November 17, 2023, at 7:45 AM leaned foreward in his wheelchair and fell, sustaining an abrasion on his left lateral forehead
-November 17, 2023, at 5:49 AM leaned foreward in his wheelchair and fell, hitting his forehead on the floor. Staff placed him back into his wheelchair and he hit his head a second time on the door, sustaining an abrasion to his mid forehead, and a left frontal scalp abrasion. He was taken to the hospital and admitted with a left frontal scalp hematoma and a lumbar 1 fracture.
-November 22, 2023, at 8:10 PM leaned foreward in his wheelchair and fell, sustaining an abrasion to his mid forehead with swelling
-December 7, 2023, at 3:30 P.M., leaned foreward in the wheelchair, falling onto his forehead, receiving an abrasion to his mid forehead and bridge of his nose
-December 10, 2023 at 4 PM leaned foreward in the wheelchair and fell, sustaining an abrasion to the left temple area with bleeding noted.
-January 8, 2024, at 9:15 AM he leaned foreward in his wheelchair and fell, sustaining an abrasion to his forehead.
-January 18, 2024 at 6 PM he leaned foreward in his wheelchair and fell, foreward, sustaining a bloody nose and a laceration above his left eye
-June 11, 2024 at 5:54 PM stood up from the wheelchair, he leaned towards his left side and fell.
A review of occupational therapy (OT) notes indicated that the resident was referred to OT with services rendered from September 16, 2023, through October 20, 2023 related to repeated falls from his wheelchair.
An OT encounter note dated October 2, 2023, indicated that OT continued to trial the resident in a standard wheelchair with foam cushion and right lateral support. During observation, patient participated in therapy tasks, however, when pieces dropped onto the floor, patient attempting to reach down to pick up but this position does place patient at risk for falling. Patient required cues to adjust posture when he sat back up due to leaning over to the right side. At this time, patient may need direct supervision when he is positioning in standard wheelchair.
OT discharge documentation dated October 20, 2023, indicated that the resident was noted to propel in the standard wheelchair with the use of his bilateral lower extremities. With propulsion, the resident continues to lean forward in attempt to gain momentum to move the chair.
The resident had multiple falls after this therapy period as noted above.
The resident fell from his wheelchair, leaning out of the chair November 17, 2023, twice with resulting injuries of a scalp hematoma and lumbar one fracture. The planned intervention following this fall with injury was to refer him to therapy to reassess his wheelchair seating.
A review of occupational therapy notes revealed that Resident 65 received OT services from November 21, 2023, through December 8, 2023. OT documentation dated November 21, 2023 revealed "Resident provided with training for wheelchair propulsion. He was able to follow verbal cues to maintain upright trunk position throughout and will correct same when told to do so. Resident present for a two hour period. While not directly working with the therapist, the resident was given a variety of activities intermittently including, exercises, games, and newspaper and displayed no behavioral issues and no attempts to self transfer. The Director of Rehab consulted with the facility Director of Nursing discussing therapy and the need for an interdisciplinary team approach to addressing and managing his falls."
Incident reports revealed that the the resident continued to fall through December 2023 and January 2024. Occupational therapy for wheelchair seating was again ordered as an intervention, January 10, 2024 through January 20, 2024.
The resident had an additional fall January 18, 2024. and again June 11, 2024, while leaning foreward from the wheelchair.
The facility to demonstrate that their QAPI system had attempted to identify and effectively address the underlying cause or contributing factors to these repeated falls to timely initiate effective interventions in an effort to prevent recurrent falls of a similar nature.
During an interview July 11, 2024 at approximately 2 P.M., the Nursing Home Administrator stated that the facility could not provide additional supervision of the resident as an fall prevention intervention to prevent multiple falls, and resultant head injuries and fractured lumbar one bone.
At the time of the survey ending June 12, 2024, the facility had not yet effectively addressed the resident's behavior of leaning forward in his wheelchair, which had resulted in multiple falls and facial injuries.
There was no evidence at the time of the survey that the facility demonstrated an effective QAPI program to include evaluating outcomes, quality of care and quality of life by investigating adverse incidents and evidence of maintenance of thorough documentation to support their analysis of the data collected and any corrective actions developed and implemented.
28 Pa. Code 201.18 (b)(1)(3)(e)(1)(4) Management
28 Pa. Code 211.12 (c) Nursing Services
| | Plan of Correction - To be completed: 08/26/2024
The facility cannot retroactively correct the deficiency. The facility will continue with current interventions and adjust as needed for resident #65 disease process that results in him leaning forward. A QAPI will be conducted for residents #65 to review all current interventions and the effectiveness.
The facility will review all residents with new falls to ensure interventions are in place to prevent recurrent falls of a similar nature.
The facility will in-service all staff on the Quality Assessment and Improvement Plan.
The facility will conduct a weekly QAPI on all new falls to ensure that interventions are in place to prevent recurrent falls of a similar nature. This will be reviewed at the monthly QAPI meeting. Recommendations will be presented to the QAPI committee for review and recommendations.
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