Failure of QAA Process to Address Abuse Investigation Deficiencies
Penalty
Summary
The deficiency involves the facility’s failure to identify and implement effective plans of action through its Quality Assessment and Assurance (QAA) process to correct system failures related to its abuse policy. The facility’s written abuse, neglect, and exploitation policy dated 1/10/2024 requires immediate investigation of suspected or reported abuse, including identifying and interviewing all involved persons, focusing the investigation on whether abuse occurred, its extent and cause, and providing complete and thorough documentation. The policy also requires protecting residents from physical and psychosocial harm during and after the investigation, and mandates reporting alleged violations to the Administrator, state agency, adult protective services, and other required agencies within specified timeframes, as well as coordination with QAPI so that cases of physical or sexual abuse are reviewed and tracked by the QAA Committee. Surveyors’ review of a facility reported incident involving a resident and an alleged perpetrator, a CNA, identified multiple concerns with how the facility handled the investigation. These concerns included lack of timely notification to the State Agency, no police report being filed, failure to suspend the alleged perpetrator pending the investigation, and lack of a complete and thorough investigation into the allegation. When interviewed, the Administrator stated that abuse allegations, including this resident’s allegation, were reviewed as part of QAA and that no concerns were identified, indicating that the QAA Committee did not recognize or address the documented investigative and reporting deficiencies related to this abuse allegation.
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