Failure to Provide Adequate Supervision Resulting in Resident-to-Resident Altercations
Penalty
Summary
The facility failed to provide adequate supervision for three residents with varying degrees of cognitive impairment and behavioral health diagnoses, resulting in multiple resident-to-resident altercations. One resident with Huntington's disease and schizoaffective disorder, who had a history of poor impulse control and previous physical aggression, was involved in two separate altercations on the same day. In the first incident, this resident was redirected from the front door by a receptionist, became upset after an interaction with another resident, and physically pushed that resident, who then retaliated. A third resident was present during this event. Shortly after the first altercation, the same resident re-entered the building from the back patio and was involved in a second altercation with another resident. This second incident escalated to physical violence, with the resident striking the other multiple times in the face, resulting in a small abrasion. Interviews revealed that staff were aware of the resident's behavioral triggers and history, but supervision was limited to 15-minute checks, and there was no continuous monitoring or documentation of these checks in the electronic medical record. Staff interviews indicated a lack of clear communication regarding the resident's supervision needs and the reasons for increased monitoring. The facility's policy required monitoring and interventions to prevent escalation of aggression, but staff actions did not align with these procedures. The activity director, who was responsible for the resident during part of the monitoring period, was not fully informed of the prior incident or the specific reasons for the increased supervision. Other staff members acknowledged that the resident should have been accompanied when re-entering the building, especially given the recent altercation and known behavioral risks. The lack of adequate supervision and failure to follow established protocols directly contributed to the repeated altercations among residents.
Plan Of Correction
F 689 Free of Accidents/Hazards Element 1 Resident #702 continues to reside within the facility. Resident continues to have a 1:1 for supervision. Resident care plans were reviewed and revised as appropriate. Resident #6 continues to reside in the facility. Resident care plans were reviewed and revised as appropriate. Resident #7 continues to reside in the facility. Resident care plans were reviewed and revised as appropriate. Element 2 Like residents are identified as residents that reside within the facility involved in a resident-to-resident incident. The IDT made rounds on the like residents to ensure care planned interventions were in place in accordance with the plan of care, and any concerns were addressed. Element 3 The procedure to implement the plan of correction included: 1. IDT reviewed F 689 2. IDT reviewed the "Abuse Policy" and deemed it appropriate. 3. IDT were reeducated on the "Abuse" policy with emphasis on ensuring interventions of supervision are in place and the care plans have meaningful interventions in place and have been implemented timely. All staff were reeducated to ensure they accompany the resident away from the environment in which the behavior has occurred. Element 4 The process to ensure that the specific citation remains corrected includes: 1. The Director of Nursing or designee will review with the IDT interventions to ensure adequate supervision is in place for resident incidents. 2. The Admin will conduct rounds to ensure there is adequate supervision for residents involved in an incident. 3. Audits will be conducted weekly for four weeks then monthly for two months. Any concerns will be immediately addressed. 4. The results of the audits will be reviewed by the QAPI committee monthly for 3 months for further recommendations. 5. Any area of non-compliance will be addressed. 6. The Admin will be responsible for sustained compliance.