Failure to Prevent Resident-to-Resident Physical Abuse Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with a history of severe intellectual disabilities, anxiety disorder, and documented verbal and physical behaviors struck another resident. The incident took place as staff attempted to take the resident to their bed, during which the resident became irritable, cursed, and was left at the doorway of their room by a CNA. Another CNA witnessed the resident hit a fellow resident on the arm as the second resident was trying to leave the room. The resident who was struck did not sustain any injuries but reported feeling shocked by the event. The resident who initiated the altercation had a BIMS score of 0, indicating severely impaired cognition, and had care plans addressing verbal and physical aggression. However, these care plans did not include specific directions for staff regarding the level of supervision required to ensure the safety of other residents until after the incident occurred. Staff interviews confirmed that the resident was known to be easily agitated and had a history of combative behaviors, but the necessary supervision and interventions to prevent such incidents were not in place at the time. The facility's abuse policy outlined the need for staff training in managing aggressive behaviors and for care planning and monitoring residents with behavioral issues. Despite these policies, the staff failed to adequately supervise the resident with known behavioral risks, resulting in the physical altercation. The deficiency was identified through interviews, record reviews, and the facility's own investigative documentation.