Failure to Maintain Effective QAPI Program for Sexual Abuse Prevention
Penalty
Summary
Facility staff failed to maintain an effective Quality Assurance/Performance Improvement (QAPI) program, specifically regarding the Performance Improvement Plan (PIP) for sexual abuse. The QAPI committee did not identify or prioritize problems and opportunities based on performance indicator data, resident and staff input, or other relevant information. Despite multiple allegations of sexual abuse, including a significant incident where one resident sexually abused another in her room, the QAPI team did not implement any changes in procedures or action plans to address these issues. Meeting minutes from several months showed that abuse allegations were discussed, but no procedural changes were made. The facility's PIP documentation for incidents of inappropriate touching and abuse lacked essential elements such as baseline data and identification of barriers, and did not specify which residents were involved. The PIP was marked as ongoing, but no further information or updates were provided to the survey team. The QAPI process, as outlined in the facility's own policy, was not followed, and the committee failed to conduct root cause analyses or implement systematic actions to address the recurring abuse allegations. Interviews with facility leadership confirmed that after months of abuse allegations, the only action taken was to instruct nursing staff to report incidents to the DON and Administrator, with no changes to existing procedures. Staff were required to discuss incidents with leadership before reporting, and no new processes or interventions were introduced following the sexual abuse incident. The facility's approach to handling sexual abuse remained unchanged, limited to notifying authorities and family, without any proactive measures to prevent recurrence or address systemic issues.
Removal Plan
- The QAPI committee reviewed reportable adverse events to determine if any trends were identified, noted that some behaviors were a result of GDRs, and established a communication tool to provide to the behavioral health provider upon entrance and to schedule an exit meeting after the visit to include review of GDRs.
- An ad hoc meeting was held by the Director of Quality and Regulatory to review F-835, F-867, F-740, and F-600, and a performance improvement plan was developed.
- The policy for abuse education was reviewed to include response to sexual abuse and non-pharmacological interventions to manage behaviors.
- Patient interviews were completed by social service director to interview residents to ensure they feel safe and associate interviews to ensure they know process for reporting and can identify abuse to include sexual and physical aggression. Audit will continue until IJ removed.
- QAPI education was provided to include trending RCA to analyze resources needed to decrease or prevent reoccurrence.
- A communication tool was developed and implemented by DON to improve the communication between the behavior provider and center to provide notification of any recommendations timely. The behavior provider will meet with the DON, ADON, and/or nurse supervisor upon entrance and exit to make aware of any new recommendation and to receive report of new adverse events.
- Nurse Managers will update the patient care plan with any non-pharmacological interventions to the patient care plan.
- An audit tool was developed by DON to review patients with inappropriate behaviors to ensure they have non-pharmacological interventions noted on care plan. Audit will continue until IJ removed.
- Education of this process has been provided to the nurse leadership and behavior provider by the DON.
- Any noncompliance will be brought back through QAPI process and addressed through the PDSA framework to identify RCA through the QAPI committee.
- A daily review for oversight will be completed by the Divisional President and/or Senior Director of Clinical Standards 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/physical behavior, and QAPI review completed as indicated on reportable for trends.
- Any noncompliance noted will be addressed through written education by the Divisional President.