Failure to Implement Planned Intervention Leads to Resident Altercation
Penalty
Summary
The facility failed to provide adequate supervision and implement a planned intervention to prevent intrusive wandering by a cognitively impaired resident, resulting in a resident-to-resident altercation. Resident 91, who is cognitively intact and has a history of verbal aggression, had a care plan intervention directing the placement of a stop sign at his doorway to deter wandering residents from entering. However, this intervention was not implemented at the time of the incident. Resident 103, who is severely cognitively impaired and identified as a wanderer and elopement risk, entered Resident 91's room, leading to a physical altercation in which Resident 91 struck Resident 103. Clinical records, staff interviews, and facility investigative documentation confirmed that the stop sign intervention was not in place at the time of the incident, and observations after the event continued to show the absence of the stop sign at Resident 91's doorway. The Director of Nursing acknowledged the facility's failure to implement the planned safety measure, which may have contributed to the altercation between the two residents.