F0867

D

Failure of QAPI Process to Address Ongoing Nutritional Management Deficiencies

Tunkhannock, Pennsylvania Survey Completed on 03-24-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure its Quality Assurance Performance Improvement (QAPI) committee developed and implemented effective corrective action plans to prevent ongoing problems in the food and nutrition services department. The facility had a written QAPI policy stating it would maintain an effective, comprehensive, data‑driven program focused on care outcomes and quality of life, using evidence‑based indicators and goals predictive of desired resident outcomes. Despite this, during a survey ending in late January 2026, surveyors identified deficient practice related to timely identification of changes in nutritional parameters, implementation of appropriate nutritional interventions, and notification of the attending physician and responsible party when significant weight loss occurred.

Following that survey, the facility created a plan of correction that included reviewing current residents for significant weight loss, completing nutritional assessments, implementing interventions, adjusting care plans, and notifying physicians and responsible parties as needed. The plan also called for education of the RD and licensed nursing staff on identifying significant weight loss and appropriate notifications, as well as ongoing audits of residents with significant weight loss. However, by the time of the subsequent survey ending in late March 2026, the same types of deficiencies were still present, demonstrating that the QAPI process had not effectively corrected or prevented recurrence of the identified issues.

For one resident, weight records showed a decline from 124 pounds in early January 2026 to 114.5 pounds by late March 2026, including a 3 percent loss in one week and a 7.5 percent loss since early January. The record did not show that a re‑weight was obtained to verify this significant change. The remote RD documented weight alerts and recommended additional nutritional interventions, including increasing nutritional shakes with meals and adding a frozen nutritional treat with dinner, as well as weekly weights. There were delays of several days between the RD’s recommendations and the corresponding physician orders, and the clinical record did not show timely implementation of the recommended interventions. The record also lacked documentation that the attending physician and the resident’s responsible party were notified of the significant weight loss on the date it was identified, and the DON confirmed the failures in timely notification and implementation, indicating that the facility’s quality assurance monitoring did not detect or correct the ongoing deficient practice for this resident’s nutritional status.