Failure to Maintain Effective QAPI Program for Resident Safety and Supervision
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program to ensure adequate supervision and safety for residents at risk for elopement, self-harm, and aggressive behaviors. Multiple residents with complex behavioral and psychiatric needs, including diagnoses such as schizoaffective disorder, impulse disorder, and major depressive disorder, experienced repeated incidents of aggression, self-injury, and elopement. The facility's QAPI committee did not perform or document thorough analysis or root cause investigations following these events, nor did it develop or implement improvement plans to address the ongoing risks and incidents. One resident with a history of agitation, aggression, and elopement risk was subject to multiple behavioral incidents, including physical aggression towards staff and other residents, self-harm, and repeated attempts to exit the facility. Despite a care plan that called for 1:1 supervision and specific interventions, the resident was able to overpower staff, exit the building, and sustain injuries. The facility issued a discharge notice stating it could not meet the resident's needs, but subsequently readmitted the resident without documented changes in condition or services, and without evidence of a QAPI review or improvement plan addressing the repeated behavioral incidents and safety concerns. Two other residents eloped from the facility by breaking a window, with one stealing an unsecured staff vehicle and traveling a significant distance before being apprehended. The facility's investigation and QAPI documentation lacked data analysis, root cause identification, or evidence of systematic review as outlined in the facility's own QAPI plan. Additionally, QAPI meeting minutes and records failed to reflect recognition of substantiated abuse, neglect, or misappropriation as issues requiring action or further investigation. The facility's failure to follow its QAPI processes and to address these serious incidents resulted in a finding of Immediate Jeopardy at a widespread scope and severity.