Failure to Prevent Resident-to-Resident Altercations Due to Insufficient Supervision
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for four residents involved in two unwitnessed resident-to-resident altercations. In one incident, a resident with severe cognitive impairment, non-traumatic brain dysfunction, Alzheimer's disease, and a history of wandering entered another resident's room. The second resident, also with severe cognitive impairment, Alzheimer's disease, Parkinson's disease, and anxiety, became agitated, resulting in both residents being found on the floor kicking at each other. Both sustained minor injuries, including a skin tear and bruising. The incident was unwitnessed, and the resident who was entered upon had a care plan indicating significant anxiety about others entering their room, preferring the door open but being highly protective of personal items. In another event, a resident with severe cognitive impairment and a history of being close to others was found on the floor near another resident's room. The second resident, also with severe cognitive impairment, hallucinations, delusions, and a history of verbal and physical behaviors, admitted to pushing the first resident, stating the other had been annoying. The incident was not witnessed by staff, and the resident who was pushed did not sustain injuries. Both residents had care plans identifying risks related to proximity to others and potential for physical aggression, with interventions to redirect and separate them as needed. The facility was undergoing a transition from two secure units to one, which increased resident activity and contributed to a rise in resident-to-resident incidents. Staff interviews and documentation revealed that insufficient supervision throughout the unit was identified as a root cause of these incidents. The lack of adequate staff presence and monitoring allowed for unwitnessed altercations to occur, despite existing care plans outlining the need for supervision and redirection for residents with behavioral challenges and cognitive impairments.