Failure to Maintain Effective QAPI Program for Weight Loss Monitoring
Penalty
Summary
The facility failed to maintain an effective, data-driven Quality Assurance and Performance Improvement (QAPI) program as required by federal regulations. Specifically, the facility did not provide evidence of ongoing monitoring and documentation for a performance improvement plan (PIP) related to weight loss among residents. The QAPI program was expected to include systematic identification, reporting, investigation, analysis, and prevention of adverse events, as well as documentation of corrective actions and performance improvement activities. However, the facility was unable to demonstrate that these processes were consistently followed for residents experiencing significant weight loss. A review of the facility's Loss Performance Improvement Plan indicated that residents who experienced significant weight loss were to be reviewed weekly in risk meetings until their weight stabilized for four weeks. The plan also required appropriate notifications, Registered Dietitian consults, care plan updates, and consistent weighing practices. Despite these outlined procedures, documentation revealed that two residents identified for monitoring were not weighed according to the prescribed weekly schedule, and there was no proof of weekly risk meetings or adequate monitoring as required by the plan. During interviews, the Director of Nursing (DON) acknowledged the lack of a set plan for transitioning from restorative to a Functional Maintenance Program and admitted that documentation for weekly monitoring and meetings was not available. The facility's QAPI policy required identifying issues, developing and implementing corrective actions, and reviewing and analyzing data, but the facility was unable to provide evidence that these steps were followed for the residents in question.