Failure to Prevent Resident-to-Resident Altercation Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate staff supervision for two residents, resulting in a physical altercation. Both residents had moderately impaired cognitive skills and required varying levels of assistance with daily activities. One resident, who had end stage renal disease, COPD, and diabetes, was struck on the left side of the face by another resident with a history of urinary tract infection, bilateral below-knee amputation, and COPD. The incident occurred when the second resident, while sitting in his wheelchair and eating lunch, became verbally aggressive and called the first resident names, telling him to get out of the way. A certified nurse assistant (CNA) was present in the room and observed the verbal aggression. The CNA stood between the two residents and attempted to verbally de-escalate the situation by telling the aggressive resident to be nice. Despite this, the aggressive resident suddenly hit the other resident. The CNA later acknowledged that she should have separated the residents immediately or called for help, and that the incident could have been prevented with prompt action. Interviews with facility leadership, including the Director of Staff Development and the Director of Nursing, confirmed that the facility's policy requires immediate separation of residents during altercations to prevent harm. Review of facility policies also indicated that resident safety, supervision, and prompt intervention during altercations are priorities. The failure to separate the residents promptly and provide adequate supervision directly led to the physical altercation and the resulting deficiency.
Plan Of Correction
F689 Corrective action for residents found to have been affected by this deficiency: CNA 1 was provided a one-on-one in-service and education regarding immediate separation and de-escalation of potential resident-to-resident altercation on 8/4/25. Corrective action for residents that may be affected by this deficiency: On 7/31/25, the Director of Staff Developer/designee interviewed staff to identify any resident roommate incompatibility to ensure supervision and communication to prevent potential resident incidents. Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not reoccur: On 8/4/25 and 8/5/25, the DON/designee provided an in-service and education training to staff regarding the facility’s policies and procedures on resident-to-resident altercation; to act promptly and conscientiously to prevent and address recurrent altercations, separate immediately, and measures to calm or diffuse the situation. The Director of Staff Developer/designee will validate compliance during observation rounds daily, checking if staff are responding immediately to potential resident incidents. The Director of Staff Developer/designee will communicate findings to the DON. Measures that will be put into place to ensure that this deficiency does not reoccur: The above Plan of Correction (POC) will be reviewed in the QAPI committee for 3 months and as needed thereafter. The Administrator and/or Designee will report trends. Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not reoccur: On 8/4/25 and 8/5/25, the DON/designee provided an in-service and education training to staff regarding the facility’s policies and procedures on resident-to-resident altercation; to act promptly and conscientiously to prevent and address recurrent altercations, separate immediately, and measures to calm or diffuse the situation. The Director of Staff Developer/designee will validate compliance during observation rounds daily, checking if staff are responding immediately to potential resident incidents. The Director of Staff Developer/designee will communicate findings to the DON. Measures that will be put into place to ensure that this deficiency does not reoccur: The above POC will be reviewed in the QAPI committee for 3 months and as needed thereafter. The Administrator and/or Designee will report trends.