Failure to Provide Adequate Supervision and Timely Response to Call Lights
Penalty
Summary
The facility failed to provide adequate supervision and maintain a safe environment for multiple residents, resulting in preventable incidents. One resident, with a history of falls and dependent on staff for bathing and toileting, pressed the call light for assistance for their confused roommate but waited an hour without response. The resident attempted to transfer themselves to a wheelchair to seek help and subsequently fell. The care plan for this resident specifically required that the call light be within reach and that staff respond promptly to requests for assistance. Resident council minutes also documented general complaints about delayed call light responses, particularly during the overnight shift. In a separate incident, a resident with severe cognitive impairment and a history of dementia, schizophrenia, and psychosis was physically assaulted by another resident after an altercation in the hallway. Shortly after, the same aggressive resident assaulted a third resident, also with severe cognitive impairment and dementia, by pulling their shirt and necklace and holding them around the neck, resulting in redness and the need for first aid. Staff interviews confirmed that after the initial altercation, the aggressive resident was not adequately supervised, allowing a second assault to occur within minutes. Facility policies required prompt and appropriate interventions for residents displaying combative behaviors, including one-on-one supervision if a resident's behavior became abusive or unmanageable. Staff interviews indicated that during resident-to-resident altercations, involved residents should be separated and closely supervised to prevent further incidents. However, these procedures were not followed, leading to repeated physical altercations and injuries.