Failure to Prevent Resident-to-Resident Abuse Due to Lapses in 1:1 Supervision
Penalty
Summary
The facility failed to protect four residents from abuse, including verbal, mental, and physical abuse, as evidenced by multiple altercations between residents. Resident 1, who had a documented history of verbal and physical aggression towards both staff and other residents, was involved in several incidents: striking another resident in the face, slapping a resident's forehead, and hitting a resident's ear. These incidents occurred despite Resident 1 being placed on one-to-one (1:1) supervision, an intervention intended to prevent such behaviors and ensure the safety of others. Staff interviews and record reviews revealed that the 1:1 supervision was not consistently maintained. Staff assigned to provide 1:1 care to Resident 1 admitted to leaving him unsupervised or not maintaining visual contact, which allowed Resident 1 to approach and physically harm other residents. The Activities Director and Activities Assistant both acknowledged lapses in supervision during group activities, and the Assistant Director of Nursing confirmed that staff did not follow the required 1:1 care interventions at the time of the altercations. Additionally, another incident involved a verbal altercation between Resident 1 and Resident 4, which escalated to Resident 4 kicking Resident 1. Documentation and interviews indicated that staff were aware of ongoing tensions and previous altercations between these residents but failed to prevent further incidents. Facility policies required staff to institute measures to minimize the possibility of abuse and to ensure that residents on 1:1 supervision were always within line of sight and not left alone, but these protocols were not followed, resulting in repeated resident-to-resident abuse.