Failure of QAPI Committee to Review and Investigate Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) committee failed to review all allegations of abuse and injuries of unknown origin to ensure thorough investigations were conducted, investigations were conducted per facility policy, residents were protected, and reporting was timely. The QAPI committee did not review incidents of abuse to ensure the Abuse Policy was fully implemented for all allegations, including staff identifying, stopping, and reporting abuse. The committee also did not ensure that allegations were thoroughly investigated or that appropriate corrective actions were taken to prevent further abuse. Specific incidents were not thoroughly reviewed or investigated by the QAPI committee. These included a case where a resident was sexually abused by another resident, and two separate cases where residents sustained fractures due to injuries of unknown origin. In the case of the sexual abuse allegation, the QAPI documentation did not recognize failures in timely reporting, thorough investigation, or resident protection measures. For the injuries of unknown origin, investigative files lacked comprehensive staff and resident interviews, did not include body assessments after the injuries were identified, and failed to follow up on concerns raised by residents or their representatives. In one instance, a handwritten note suggesting possible mishandling was not investigated or traced to its source. Interviews with facility leadership, including the Administrator and DON, revealed gaps in the investigative process, such as not interviewing all potentially involved staff or residents, not documenting discussions with families, and not ensuring that all relevant information was considered. The QAPI committee meetings did not consistently identify these investigative shortcomings or develop action plans to address them, resulting in a failure to ensure that all contributing factors were identified and that appropriate corrective actions were implemented.