Medical Director Absence from QAPI Committee Meetings
Penalty
Summary
The facility failed to ensure that the Medical Director (MD), a required member of the Quality Assurance and Performance Improvement (QAPI) committee, attended any of the QAPI meetings from January to May 2025. Despite holding monthly QAPI meetings to review quality reports, identify care concerns, discuss safety issues, and implement corrective actions, the MD did not participate in these meetings. Attendance records confirmed the MD's absence, and the facility did not have a designee attend in the MD's place. Interviews with the Administrator (ADM) and Director of Nursing (DON) revealed that the MD was invited to each meeting but declined, citing being too busy. The ADM reported that the MD was verbally notified of issues and provided with written reports, but the MD did not acknowledge receipt of these reports. The facility's QAPI policy required the MD or a designee to be part of the committee, but this requirement was not met during the specified period, affecting oversight for a census of 137 residents.