Failure to Prevent Recurrence of Resident-to-Resident Sexual Abuse Due to Inadequate QAPI Oversight
Penalty
Summary
The facility failed to maintain compliance with regulations requiring the protection of residents from sexual abuse. Despite a known history of maladaptive behaviors, including inappropriate sexual comments, touching staff inappropriately, wandering into female residents' rooms, and grabbing residents' wheelchairs, one resident was not adequately monitored or included in ongoing audits intended to prevent abuse. On August 27, 2025, this resident was witnessed by staff sexually abusing another resident by touching her genital area over her clothing without consent. Clinical record reviews confirmed the perpetrator's behavioral history, but there was no evidence that this risk was addressed in the facility's quality assurance or performance improvement activities. The Quality Assurance and Performance Improvement (QAPI) committee did not identify or address the underlying causes of the original deficiency, as their plan focused only on the previously identified incident and did not evaluate or implement targeted prevention strategies for residents with known behavioral risks. Internal audits conducted after the initial survey did not include the resident with a history of maladaptive behaviors, nor did they monitor the effectiveness of corrective actions beyond the initial audits. As a result, the facility's failure to identify and address these risk factors contributed to the recurrence of resident-to-resident sexual abuse.