Failure to Prevent Resident-to-Resident Altercation Due to Inadequate Supervision
Penalty
Summary
Staff failed to effectively intervene when two residents became agitated and began yelling at each other in a common area, resulting in one resident sustaining a skin tear after being struck on the hand with a cellphone by another resident. Both residents had documented histories of behavioral issues, including aggression and agitation, and their care plans included specific interventions to address escalating behaviors. Despite these documented risks and interventions, staff present in the lobby did not redirect or separate the residents when signs of agitation and verbal confrontation began. On the day of the incident, several residents and staff were gathered in the lobby watching bears outside the facility entrance. One resident, who was cognitively impaired and had a history of violent behaviors, became agitated after another resident, who was cognitively intact but anxious and verbally aggressive, began yelling about the bears. The two residents exchanged shouts of "shut up" before the cognitively impaired resident approached and struck the other with a cellphone. Staff present at the time were distracted by the bears and did not intervene to de-escalate the situation or remove either resident from the area prior to the physical altercation. Interviews with staff confirmed that they were aware of both residents' behavioral histories and care plan interventions but did not act to prevent the escalation. Staff acknowledged that they could have redirected or separated the residents but were focused on the unusual event of the bears outside. The incident resulted in a skin tear to one resident, which required first aid, and highlighted a lapse in supervision and adherence to established care plan interventions for residents with known behavioral risks.