Systemic Failure to Prevent and Address Resident Abuse Due to Ineffective QA Program
Penalty
Summary
Facility staff failed to maintain an effective quality assurance program focused on outcomes of care and quality of life, resulting in multiple residents across all units being victims of abuse. Survey findings revealed that seven residents were abused by staff and/or other residents, with failures in reporting allegations, investigating incidents, and preventing further abuse. The facility's quality assurance program was involved in developing a plan of correction and ongoing monitoring, but these actions did not sustain compliance. During a subsequent survey, nine residents were identified as victims of abuse, with continued failures in reporting, investigation, and supervision, leading to deficiencies in abuse prevention and quality of care. Further review showed that the facility was previously cited for failing to protect residents from abuse, failing to report and investigate abuse, and not correcting repeated willful abuse. Despite audits and staff education on abuse policies, additional residents were found to have been abused, and immediate jeopardy was identified due to the facility's failure to protect residents' rights. The facility did not implement interventions such as 1:1 supervision, psychiatric services, timely reporting, thorough investigations, and staff education as outlined in their plan of correction. The DON acknowledged the lack of evidence for an effective QA program, and the administrator was not available for interview.