Failure to Protect Residents from Abuse and Inadequate Oversight
Penalty
Summary
Facility administration failed to provide protective oversight to ensure the highest practicable physical and psychosocial well-being of residents. Specifically, administration did not take appropriate action on allegations of resident-to-resident physical and sexual abuse. One resident, who had a history of sexually aggressive behaviors, entered another resident's room and sexually and physically assaulted her. Staff and the DON were aware of prior threatening behaviors by the perpetrator, including threats to staff, but there was no evidence of effective monitoring or intervention to address these behaviors before the incident occurred. The administration did not complete a thorough investigation or implement non-pharmacological interventions for residents with inappropriate behaviors, as required. Behavioral health notes confirmed that the resident with aggressive behaviors was seen by a behavioral consultant, but there was no documentation or evidence that interventions specifically targeting sexual behaviors were put in place. The facility also failed to update or change procedures after multiple abuse allegations, and the QAPI team did not implement new plans or monitoring systems in response to these events. Additionally, the administration did not ensure that concerns related to abuse prevention were identified or that QAPI plans were implemented to address resident-to-resident abuse. The facility's abuse policies were not fully enacted, and there was a lack of systematic feedback, data collection, and monitoring for adverse events. The administrator could not recall details of the incident and did not take further action to revise processes or provide additional staff education following the assault, despite multiple allegations of abuse within the facility.
Removal Plan
- Police was notified by DON regarding the incident for R121 and an arrest was made.
- Ad hoc QAPI and performance improvement plan (PIP) was developed and initiated by the Director of Quality and Regulatory Services (DOQRS). The meeting discussion included plan development and citations issued for F-835, F-867, F-600, and F-740. The Medical Director was made aware by the Director of Nursing. The existing Abuse policies were reviewed and concluded no revisions were needed.
- The Division [NAME] President provided education to the Administrator on job description to include roles, responsibilities, and duties to ensure the safety of all residents. Education provided on the abuse prohibition policy to include reviewing adverse events during QAPI, recognizing trends to create proactive measures to reduce further reduce reoccurrences to ensure the safety of all residents.
- Corrective action for other residents having the potential to be affected by the same deficient practice.
- All residents who reside in the center have the potential to be impacted by the deficient practice.
- Systemic changes were made to ensure that the deficient practice would not recur.
- Oversight was provided by the Divisional Nurses (DN), Program Director of SSD, and Divisional [NAME] President (DVP) to ensure the Administrator and the DON were informed about and adhered to the Abuse policy in their day-to-day operations. The administrator was placed on administrative leave pending investigation, and oversight was provided by the Senior Director of Clinical Services (SRDCS). Oversight was provided by the Senior Director of Clinical Services (SRDCS), Program Director of SSD, and Director of Quality and Regulatory Services (DQRS). Education was provided to Administrator Assistant by DVP to ensure the day to day operations were being followed to include adhering to the Abuse policy, QAPI education was also provided to the leadership team to include monitoring and follow-up for adverse events and being proactive by tracking and trending to identified what resources are needed to be proactive when inappropriate behavior is noted by Director of Quality and Regulatory Services and Sr Director of Clinical Standards. DVP, Sr. DCS, and DORQ confirmed that education had been completed with staff on abuse, including intervening to protect a patient from further abuse. DVP and/or DN completed a review to ensure that audits were completed for F600, F867, and F740, ensuring that patients were safe, and that staff understood the education on non-pharmacological interventions for inappropriate sexual behavior, and QAPI review completed as indicate on reportable for trends. Audits will continue until the removal of IJ.
- Quality Assurance Plans were implemented to monitor facility performance, ensuring that corrections are implemented and remain permanent. An audit tool was developed and initiated by the Assistant Administrator and is being used daily to monitor the implementation of the Plan of Correction. The Assistant Administrator, Director of Nursing, or Assistant Director of Nursing will be responsible for ensuring the completion of this tool. The audits will be validated by the Governing body to include DVP, SrDCS, DOQR, and/or DN. The results of the monitoring completed under this plan of correction will be submitted monthly to the QAPI committee for review and further follow-up. The Audit tool will continue until the QAPI committee deems it is no longer necessary. Any noncompliance noted will be addressed through written education by the Divisional [NAME] President.