Inadequate Staffing Leads to Resident Altercations and Unsafe Supervision in Memory Care Unit
Penalty
Summary
The facility failed to provide adequate nursing staff in the locked memory care unit, resulting in insufficient supervision and care for residents. On multiple occasions, residents were observed without staff supervision, leading to resident-to-resident altercations and unsafe behaviors. One incident involved a resident pacing the hallway unsupervised, using derogatory language, and physically assaulting another resident by pinching and hitting her, which caused the victim to scream. Staff intervened only after the altercation had escalated, and the aggressive resident was left unsupervised again, leading her to interact inappropriately with another resident. Further observations revealed that a group of residents was left alone in the dining room without any staff present, during which time one resident attempted to push another in a wheelchair, causing visible distress. Other residents were seen moving around the dining room without assistance, and one resident was observed entering other residents' rooms unsupervised. Interviews with staff and a family member confirmed that the memory care unit was often understaffed due to call-ins, resulting in residents being left without adequate supervision. The facility's own assessment indicated that dementia care is a specialty area and requires specific staffing, which was not consistently provided.