QAPI Oversight Failure Leads to Missed Restorative Nursing Treatments
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to provide adequate oversight of the Restorative Nursing Assistance (RNA) program, resulting in residents not receiving treatments as ordered by physicians. A review of the Restorative Program Monthly Audit for April 2025 revealed 84 missed RNA visits among 13 residents. Additionally, the Order Listing Report indicated that 22 residents were currently receiving RNA services. Despite these missed treatments, neither the Director of Nursing (DON) nor the Director of Rehabilitation (DOR) were aware of any issues with the RNA program. The DOR stated that her responsibilities were limited to staff training and entering RNA orders, while the DON only performed a cursory review of weekly progress notes without verifying that treatments matched physician orders. Further review of QAPI meeting minutes from October 2024 to April 2025 showed no discussion or identification of concerns related to the RNA program. The facility's QAPI plan referenced monitoring clinical care through consultant evaluations, MDS-QI scores, and surveys, but there was no evidence that these tools were used to identify or address the missed RNA treatments. The lack of oversight and failure to audit the RNA program led to residents not receiving the prescribed restorative nursing services.