Failure to Prevent Resident-to-Resident Physical Abuse Due to Lack of Supervision and Behavioral Monitoring
Penalty
Summary
The facility failed to protect a resident from physical abuse when two residents, both with significant psychiatric diagnoses, were left unsupervised and engaged in an altercation on the facility patio. Both residents had documented requirements for supervision while smoking, as indicated in their Smoking Assessment Forms, and were supposed to be monitored at all times during smoking activities. Despite these requirements, the residents were able to access the patio unsupervised during the early morning hours, outside of the scheduled smoking times, and became involved in an argument that escalated to one resident physically assaulting the other, resulting in a cut and swelling to the victim's lip. Prior to the incident, one of the residents exhibited escalating behaviors, including yelling, demanding cigarettes, pacing the hallways, and expressing paranoid thoughts about being given methamphetamine. These behaviors were observed by nursing staff throughout the night, but the resident's physician was not notified, and no additional monitoring or intervention was implemented. The assigned CNA was unaware of the residents' whereabouts during her shift and did not recall the altercation, despite being responsible for their care. Staff interviews confirmed that residents were not supposed to smoke at night and that supervision protocols were not followed. Facility policies required staff to supervise residents during smoking, maintain control of smoking materials, and monitor residents with behavioral issues. However, these policies were not adhered to, as evidenced by staff statements and documentation. The lack of supervision and failure to address escalating behaviors directly led to the unsupervised altercation and subsequent injury. The incident was deemed avoidable by facility leadership, who acknowledged that proper supervision and behavioral management were not provided.