F0867

E

Failure to Analyze and Trend Resident-to-Resident Abuse Incidents in QAA/QAPI

Scottsdale, Arizona Survey Completed on 03-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to track, trend, and analyze resident-to-resident abuse incidents and to implement a measurable, data-driven prevention plan through its Quality Assessment and Assurance (QAA) process. Review of QAA meeting minutes for a December meeting covering November showed that the number of reportable incidents for November was left blank, despite trends indicating multiple incidents across specific units. The Director of Nursing’s clinical systems review did not specifically address resident-to-resident abuse, and the documented action plan remained a general approach focused on education about behaviors, memory care, and keeping residents at arm’s length, without measurable elements. The section for resolved action plans was left blank, and there was no documentation of measurable progress on preventing resident-to-resident abuse.

Further review of QAA minutes for a February meeting covering December and January showed inconsistencies between the total number of reportable incidents and the number of incidents listed by unit, and again reflected the same non-specific action plan without measurable outcomes. Interviews with the DON and the Administrator confirmed that resident-to-resident altercations were only tracked as reportable events and primarily by location, with no deeper trend analysis such as triggers, patterns, or other causative factors. The Administrator acknowledged that trend tracking for resident-to-resident abuse did not go far enough, and the DON stated that the facility did not know what triggered residents, relying on psych services after altercations. These practices did not align with facility policies requiring QAPI review and analysis of all abuse-related occurrences and integration of confirmed abuse findings into performance improvement initiatives.