Deficiencies in Abuse Prevention and Dementia Care
Penalty
Summary
The facility failed to implement effective interventions to prevent resident abuse, dementia care, and unnecessary psychoactive medication use. An incident involving a resident, identified as Resident A16, occurred on December 27, 2024, where the resident was physically mishandled by staff, escalating into verbal threats and inappropriate conduct. This incident was not identified as abuse or appropriately addressed by the facility's QAPI committee. Resident A16, who exhibited aggressive and disruptive behaviors with documented cognitive impairments, did not receive care aligned with his plan of care, including 1:1 supervision. The facility's interventions were inadequate to address the resident's behaviors and care needs, resulting in repeated incidents of wandering, aggression, and unsafe situations. Additionally, the facility failed to ensure physician documentation met criteria for the continued use of psychoactive medications prescribed to Resident A16, lacking resident-specific rationale or evidence of compliance with gradual dose reduction requirements. Despite implementing a directed plan of correction after a previous survey, the facility failed to sustain corrective measures. Monitoring plans to audit abuse prevention, dementia care interventions, and psychoactive medication use did not identify ongoing deficiencies. Interviews with the Director of Nursing and Nursing Home Administrator confirmed that the QAPI committee did not adequately identify root causes, analyze trends, or implement sustained corrective actions to address the continued deficiencies.
Plan Of Correction
- The QA process reviewed by the temporary management company on 1/22/2025. - QA committee observation completed 1/22/2025 by the temporary management company. Review of current identified areas of needs identified through survey process and facility identified issues. - Re-education completed by the temporary management company to facility department heads and administration on policy entitled, "Quality Assurance and Performance Improvement (QAPI)." - Audits will be completed monthly and prn by the temporary management company x 3. - Audit will be presented at the monthly QAPI committee for ongoing oversight.