Failure to Use QAPI to Maintain Restorative Care and Adequate Nurse Aide Services
Penalty
Summary
The deficiency involves the facility’s failure to use its Quality Assurance Performance Improvement (QAPI) program to ensure effective delivery of care and services, specifically related to the restorative program and nurse aide staffing. The facility’s written Performance Improvement Program Plan states that it is the policy of the facility to continually improve the delivery of health care services by designing, measuring, assessing, improving, and redesigning processes of resident care, and that new or modified processes should meet criteria such as being clinically sound, meeting the needs of staff and individuals served, and incorporating results of performance improvement activities. Despite this written plan, the facility did not apply its QAPI processes when making changes to the restorative program and reallocating duties to nurse aides. During a confidential resident group interview, residents reported that the restorative program had been discontinued and that restorative duties had been placed on nurse aides. The residents in the group confirmed that they were not receiving restorative care. Review of Resident Council minutes from a prior meeting showed that residents had already expressed concerns that the restorative program had been discontinued, indicating that this issue had been raised through resident feedback mechanisms before the survey. In an interview, the Nursing Home Administrator (NHA) confirmed that the facility was in the state enforcement process for a lack of nurse aide care, with issues dating back several months, and that residents, the Resident Council, the local Ombudsman, resident interviews, and facility staffing data all indicated that nurse aide staffing was insufficient to meet basic resident care needs. When asked, the NHA confirmed that the facility had not used its QAPI process and plan to ensure effective delivery of the restorative program and acknowledged that, had the QAPI plan been utilized, it would have shown that assigning additional restorative duties to already short-staffed nurse aides was not a feasible replacement for the discontinued restorative program. The NHA further confirmed that the QAPI committee failed to ensure that the delivery of care and services was effectively provided to residents.
Plan Of Correction
A Quality Assurance and Performance Improvement (QAPI) will be held by the Administrator/Designee on May 11, 2026 Resident recently discharged from Therapy will be assessed by both the Therapy department and Nursing for the need for any restorative programming. A POC task for documentation will be created to ensure the program is completed by the CNA. When Staff in is insufficient to provide these services the Therapy Department staff will assist. The DON/Designee will Monitored the when the need for the therapy staff to assist occurs A Quality Assurance and Performance Improvement (QAPI) will be held by the administrator/Designee at least quarterly or more often if needed. Minutes of the QAPI committee will be presented to the Governing Body of the Greenery Center for Rehab and Nursing. The Management Team will be educated on the timing and requirement of the QAPI committee by the Administrator. The Governing Body of the Greenery Center for Rehab and Nursing will monitor for compliance of this regulation. The DON/Designee will audit the Restorative care documentation on the CNA task weekly times four and monthly times two. The DON/ Designee will monitor the need for therapy to assist ongoing
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