Failure to Address Abuse Allegations in QAPI Process
Penalty
Summary
The facility failed to implement an effective Quality Assurance Performance Improvement Committee (QAPI) plan to address allegations of abuse arising from resident grievances. Review of resident concern and grievance logs showed that, since June 2024, there were 15 grievances from 15 residents that were not identified as allegations of abuse. According to the facility's QAPI policy and procedure, resident concern summary logs were to be used for identifying improvement priorities, but these logs were not utilized to identify abuse concerns. During an interview, the administrator confirmed that the QAPI committee met monthly with all required members present, but no performance improvement plans were in place, and allegations of abuse had not been recognized as a concern by the committee. Review of the most recent QAPI meeting minutes showed no discussion or identification of abuse allegations, despite the presence of multiple resident concerns in the logs.