Failure to Provide Adequate Supervision for Resident with Aggressive Behaviors
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision to a resident with severe cognitive impairment and a history of behavioral disturbances, including physical aggression. The resident, diagnosed with dementia, anxiety disorder, and major depressive disorder, had multiple care plans indicating a risk for psychosocial distress and physical aggression, with interventions such as one-on-one care and frequent observation. Despite these interventions, the resident was involved in several resident-to-resident altercations, as documented in the facility's incident log and progress notes. One incident involved the resident physically striking another resident in the dayroom after a dispute over seating. Clinical documentation and behavior charting assessments revealed ongoing agitation, aggression, and poor boundaries, with interventions such as redirection and, at times, 1:1 monitoring. However, the implementation of 1:1 monitoring was inconsistent, as not all assessments indicated this level of supervision. Staff interviews confirmed that one-on-one care was only consistently provided after repeated incidents of aggression. The facility's policy required measures to minimize the possibility of abuse and address problematic resident behavior, but the failure to provide consistent supervision led to preventable altercations.