Failure to Implement Comprehensive QAPI Program
Summary
The facility failed to implement and maintain a comprehensive Quality Assurance and Performance Improvement (QAPI) program that addressed the full range of care and services, focusing on quality of life, quality of care, and services to residents. Specifically, the facility did not ensure an ongoing QAPI program was in place to address identified priorities, including ongoing concerns of physical and sexual abuse involving a resident. The facility's policy indicated that the Quality Assessment and Assurance (QAA) Committee should meet quarterly to identify quality deficiencies and develop plans of action, but this was not effectively executed. The resident involved, admitted in September 2021, had diagnoses including conduct disorder, major depression, and dementia with behavioral disturbance. The medical record showed a history of agitation, aggression, intrusive wandering, hitting other residents, and sexually inappropriate behaviors. Despite these ongoing issues, the facility failed to provide evidence that the interdisciplinary team discussed and addressed the resident's behaviors or implemented interventions to prevent further incidents. Interviews with the Director of Nursing (DON) and the Administrator revealed awareness of the resident's history of aggression and inappropriate behaviors. However, the Administrator was unable to provide evidence of any action plans or interventions put in place to address these issues. The QAA committee's activities, as reported by the Administrator, did not include addressing the concerns of physical and sexual abuse, nor did they develop and implement plans to correct these deficiencies, ensuring the safety of the resident and others in the facility.
Penalty
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