Failure to Prevent Resident-to-Resident Abuse Due to Inadequate Supervision
Penalty
Summary
A cognitively intact resident with a history of behavioral issues, including aggression toward staff and other residents, was involved in a physical altercation with a moderately cognitively impaired resident. The aggressive resident had documented behaviors such as throwing items, cursing, and hitting, and was supposed to be under close supervision, including 15-minute checks and being kept at the nurse's station due to agitation earlier in the day. Despite these interventions, the resident was able to leave the nurse's station and enter the courtyard, where the incident occurred. On the day of the incident, the aggressive resident exhibited escalating behaviors, including attempting to hit a physician and being verbally abusive. Staff, including the Rehabilitation Director and a Physical Therapy Assistant, intervened during these episodes but were unable to prevent the resident from later accessing the courtyard. In the courtyard, the resident engaged in an argument with another resident and subsequently struck him multiple times with an ashtray holder, causing several small skin tears on the victim's arms and finger. Witnesses, including a medication aide and a housekeeper, intervened to separate the residents and remove the weapon. The incident was reported by staff who witnessed the altercation, and it was confirmed that the aggressive resident was not under one-to-one supervision at the time of the event, despite prior behavioral concerns and interventions. The staff interviewed were unclear about the timing and implementation of the one-to-one observation, and the Director of Nursing was unable to explain how the resident left the nurse's station. The failure to maintain effective supervision and prevent the resident from accessing and harming another resident resulted in a deficiency related to protecting residents from abuse.