Failure to Address Resident Weight Loss in QAPI Process
Penalty
Summary
The facility failed to identify and address weight loss trends among residents as part of its Quality Assurance Performance Improvement (QAPI) process. During interviews and record reviews, it was revealed that the QAPI meetings focused on issues such as elopement prevention and resident-to-resident altercations, but did not include discussions about resident weight loss. The Director of Nursing acknowledged that monitoring and addressing weight loss should have been part of the QAPI agenda, as it is a critical aspect of patient care. As a result, the facility did not implement a systemic approach to address the weight loss experienced by two residents, which was not recognized or acted upon prior to the recertification survey. A review of the facility's QAPI policy confirmed that its purpose is to monitor, evaluate, and improve the quality of resident care, and that staff at all levels are expected to identify and solve quality concerns. Despite this, the facility did not identify weight loss as an area requiring action, leading to the deficiency.