Failure to Provide Adequate Supervision Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment and a history of aggression was punched in the stomach by another resident with severe cognitive impairment and a documented pattern of physical aggression. This incident caused the first resident to fall and hit her head on a metal door frame, resulting in a head laceration and visible discoloration on her shoulder. The event was witnessed by a staff member, and documentation confirmed the injury and the circumstances leading to it. Both residents involved had histories of behavioral disturbances, with one resident's care plans noting multiple episodes of physical aggression, agitation, and aggression. Staff interviews confirmed that both residents had previously exhibited aggressive behaviors. The facility's policy emphasized the importance of resident safety and supervision, but the incident demonstrated a failure to provide adequate supervision and prevent accidents between residents with known behavioral risks.
Plan Of Correction
F 689 CORRECTIVE ACTIONS FOR RESIDENTS AFFECTED BY THIS DEFICIENT PRACTICE. Resident #1 and Resident #2 were immediately separated. Two staff members re-directed Resident #2's behavior and stayed with the resident until 911 paramedics arrived. Resident #1 was assessed from head to toe, provided first aid treatment, and staff members stayed with the resident. Both residents were assessed for emotional distress and given reassurance. Both residents were transferred to the hospital for further evaluation and treatment. CORRECTIVE ACTIONS TAKEN TO THOSE RESIDENTS IDENTIFIED THAT HAVE THE POTENTIAL TO BE AFFECTED BY DEFICIENT PRACTICE. All residents with interactions with Resident #2 can be affected by this deficient practice. Upon notification of the incident, the supervisor and all licensed nurses on duty conducted rounds on all residents to determine if they had any interactions with Resident #2, and none were found. No other residents were affected by this deficient practice. SYSTEMIC CHANGES IMPLEMENTED BY FACILITY TO ENSURE DEFICIENT PRACTICE DOES NOT RECUR. The Director of Staff Development (DSD) conducted an in-service with staff on 4/17/25 on Residents' Rights on 04/17/2025. The IDT team will assess and identify residents at least quarterly or as necessary. Residents with challenging behaviors will have their POC updated to include de-escalation techniques and strategies, and the POC will be implemented to provide adequate supervision to prevent accidents. FACILITY'S PLAN TO MONITOR THAT SOLUTIONS ARE SUSTAINED. The Social Services Director (SSD) and/or designee will be the process owner who will monitor the plan of care that is in place and is implemented to ensure all residents are safe and have adequate supervision from staff. Any trends and discrepancies will be brought to the facility's QAPI committee for review and additional guidance or recommendations. DATE CORRECTIVE ACTIONS WILL BE COMPLETED. 04/21/2025