Failure to Implement Effective QAPI Program for Resident Care Concerns
Penalty
Summary
The facility failed to effectively utilize its Quality Assessment and Performance Improvement (QAPI) program to identify and address multiple resident care concerns. Specifically, the facility did not monitor or identify weight loss in a resident, nor did it recognize weight loss as a problem in other residents. The Assistant Director of Nursing (ADON) confirmed during an interview that the facility did not review the comprehensive care plan for the affected resident or address the issue through an interdisciplinary team meeting. Additionally, the facility was focused on other areas such as falls and skin and wound management during the relevant period, and did not address the ongoing issue of weight loss. Further deficiencies included the failure to follow recommended Restorative Nursing Assistant Program exercises as prescribed by Physical Therapy, lack of accurate documentation by Restorative Nursing Assistant Services, and lapses in infection control practices. Staff were also observed not following proper feeding techniques, such as standing over a resident while feeding, and the facility did not follow up on a missed outpatient appointment. These actions and inactions were confirmed through interviews and record reviews, and were not addressed through the facility's QAPI processes as required by their policy.