Failure to Prevent and Address Repeated Sexual Abuse Incidents
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program, resulting in repeated deficiencies related to sexual abuse. Despite having a QAPI policy and a plan of correction from a previous survey, the facility did not ensure that concerns related to sexual abuse were properly identified or addressed. During the survey, it was found that multiple residents experienced incidents involving inappropriate sexual contact or behavior from another resident. Specific incidents included a resident being found in bed with her pants down and a perpetrator standing over her, another resident's guardian reporting unwanted touching and disturbances in her room, and additional residents being subjected to inappropriate physical contact in common areas. Staff interviews confirmed that these incidents were not effectively managed or prevented by the facility's quality assurance systems. The repeated nature of these incidents, affecting five residents, demonstrates that the facility's QAPI committee did not adequately monitor, evaluate, or correct the issues related to sexual abuse. The documentation review showed that the facility had previously identified similar problems and developed corrective actions, but these measures were not successful in preventing recurrence. The failure to implement and sustain effective quality assurance processes allowed the same types of abuse to continue, as confirmed by both staff and guardian interviews during the survey.