Failure of QAA Committee to Address and Correct Quality Deficiencies Leading to Resident Sexual Abuse
Penalty
Summary
The facility's Quality Assessment and Assurance Committee (QAA) failed to develop and implement appropriate plans of action to correct identified quality deficiencies, particularly those that resulted in adverse outcomes. This failure was evident in the lack of improvement in systems and processes, which contributed to an incident of sexual abuse involving a female resident with severe cognitive impairment and a male resident. The QAA did not initiate or follow through with performance improvement projects or ad hoc QAPI meetings after the incident, and the Medical Director was not promptly informed of the event or the transfer of the involved male resident. The female resident involved had a history of severe cognitive impairment, aggressive behaviors, and required significant assistance with personal care. Her care plan documented behavioral issues, including aggression and inappropriate behaviors, but monitoring orders were inconsistently implemented and discontinued without documentation of increased supervision. On the day of the incident, staff observed escalating inappropriate interactions between the two residents but did not maintain adequate supervision, resulting in the female resident being found in the male resident's bed with evidence of inappropriate sexual contact. The male resident had moderate cognitive impairment and no prior psychiatric diagnoses or behavioral issues documented before the incident. After the event, his care plan was updated to include interventions for hypersexuality, but there was no intervention for increased supervision from the time of the incident until his transfer. Staff interviews revealed that administrative and clinical leadership did not conduct an ad hoc QAPI meeting or ensure timely communication with the Medical Director. The facility's QAPI policy required proactive and comprehensive quality improvement actions, but these were not followed in response to the incident.