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Based on clinical record review, staff interview, facility document review and during the course of a complaint investigation, it was determined the facility failed to ensure the Quality Assessment of Performance Improvement (QAPI) program was effectively monitoring and reviewing patient care concerns thus failing to substantially comply with this condition.

The findings include:

The facility has an outstanding condition level deficiency related to the QAPI program based on survey findings for complaints #VA00050091 and VA00050244. This complaint survey revealed an additional QAPI related deficiency.

Please refer to A0286 for further information.

Based on interviews, record reviews and during the course of a complaint investigation, it was determined the facility failed to thoroughly investigate and review an allegation they received related to patient abuse.

The findings include:

On 12/28/2020, the surveyor received a document titled, Risk Management Investigation 12/4/2020. This document was in reference to a complaint investigation the surveyor was conducting. The document outlined the allegation received by the facility, the investigation conducted, the conclusion, and the follow up action. Staff Member (SM) #4 (Director of Risk) conducted the investigation, which included interviewing the patient (Patient #2) of the alleged abuse, two peers of the patient, and a review of camera footage. The document read in part: "Conclusion: Due to lack of evidence and statements above this allegation has been found to be false."

On 12/28/2020, the surveyor reviewed the clinical record for Patient #2. On 12/1/2020 at 2200, a progress note was written by SM #11 (Behavioral Tech.) documenting their eyewitness account of an incident that occurred between Patient #2 and SM #8 (Registered Nurse). On 12/1/2020 at 2240, a progress note was written by SM #9 (Registered Nurse) documenting their eyewitness account of the incident that occurred between Patient #2 and SM #8. On 12/2/2020, a medical progress note contained evidence that SM #12 (Certified Pediatric Nurse Practitioner) was aware of the incident involving Patient #2 and a concern from Patient #2 that "a nurse was allowing patients to access [the nurse's] phone" and that the "concern has been escalated to the Risk Manager and CNO [Chief Nursing Officer] for further investigation.

An interview was conducted on 12/28/2020 with SM #6 (Corporate representative) and SM #4. SM #4 explained the investigation was conducted by reviewing the record and video footage and conducting interviews with the patient and peers. SM #4 stated, "I was not able to conduct interviews with the nurses." SM #4 did not provide further explanation as to why the interviews could not be conducted. SM #6 stated, "This is the first I am seeing of this report. We are in the process of changing wording and will no longer be using the word false. The word false gives the wrong impression like none of the allegation happened."

The investigation documentation presented to the surveyors revealed a failure to thoroughly conduct a complete investigation. There was no documentation that an attempt was made to interview the nurses involved, the behavioral technician involved, or any follow-up conducted with SM #12 to gather additional information. Additionally, a review of the investigation results had not been conducted by any member of the leadership staff prior to 12/28/2020. On 12/29/2020, the surveyors discussed the concerns regarding the internal investigation of the allegation with SM #2 (Chief Operating Officer), #4, and #6. SM #2, SM #4, and SM #6 acknowledged the concerns and discussed the changes the facility is making moving forward.

Prior to the exit conference on 12/29/2020, the surveyor was provided an amended copy of the document titled, "Risk Management Investigation 12/4/2020". The document reads in part: "Conclusion: Based on this investigation it was reviewed that the patient's behavior/actions of pouring the shampoo on the RN [Registered Nurse] was substantiated. The act of the RN pushing the pt. [patient] was unsubstantiated due to lack of witnesses, and no video footage due to the incident occurring outside of camera view."