Failure to Implement Supervision and Safety Interventions for Resident with Aggressive Behavior
Penalty
Summary
The facility failed to ensure adequate supervision and implementation of safety interventions for a resident with a history of aggressive behavior. Specifically, a resident diagnosed with Dementia, Paranoid Schizophrenia, and Alzheimer's Disease, who had previously been involved in an incident with another resident, was not kept away from female residents as directed in their care plan. Three days after the initial incident, this resident grabbed another resident's wrist and shirt and attempted to strike her while both were sitting in the hallway. The care plan clearly stated that the resident should be kept away from female residents and not be left alone with them, but this was not followed. Staff interviews revealed that both the licensed nurse and the certified nursing assistant involved were unaware of the care plan instructions regarding the resident's required separation from female residents. The Director of Nursing acknowledged that the care plan was not fully implemented and that the resident was not placed on one-to-one monitoring after the first incident. This lack of communication and supervision allowed the incident to occur, potentially affecting the physical and psychosocial well-being of the resident who was grabbed.