Failure to Supervise Resident with Wandering and Aggressive Behaviors
Penalty
Summary
The facility failed to provide adequate supervision to prevent a male resident with a history of wandering and severe cognitive impairment from entering an occupied female restroom. The male resident, who had diagnoses including schizoaffective disorder and was noted to be resistant to redirection with poor impulse control, entered the restroom while a cognitively intact female resident was using it. This resulted in the female resident being exposed and subsequently punched in the right cheek by the male resident. Observations on multiple occasions revealed that no staff were present in the hallways near the resident rooms, and interviews confirmed the male resident's history of wandering into other residents' rooms. The facility's policy required increased observation for residents presenting risks such as aggression or assault, but this was not implemented effectively, as staff were not present to monitor or intervene during the incident.