Failure to Supervise Residents During Smoking Results in Resident-to-Resident Altercation
Penalty
Summary
The facility failed to ensure that two residents, both assessed as requiring supervision while smoking, were adequately monitored while smoking on the patio during the early morning hours. Both residents had documented mental health diagnoses, with one having moderately impaired cognitive skills and fluctuating decision-making capacity, and the other with intact cognition but a history of aggressive behavior. Facility records, including Smoking Assessment Forms and care plans, specified that both residents must be supervised at all times while smoking and required the use of protective non-flammable aprons. Despite these requirements, both residents were left unsupervised on the patio, outside of the scheduled smoking times, and were able to access cigarettes without staff oversight. On the night in question, one resident exhibited escalating aggressive behavior, repeatedly requesting cigarettes from staff, pacing the hallways, and making threats. Staff interviews confirmed that there were no scheduled smoking breaks during the night shift, and that residents were not supposed to have cigarettes or lighters in their possession. However, both residents managed to access the patio and smoke unsupervised. During this time, an altercation occurred between the two, resulting in one resident being punched multiple times in the face and sustaining a cut and swelling on the lip. The incident was reported by the injured resident upon re-entering the facility, and staff observed visible injuries. Interviews with facility staff, including CNAs, LVNs, the Director of Staff Development, and the DON, revealed a lack of awareness and supervision regarding the residents' whereabouts and activities during the night. Staff acknowledged that supervision was required for both residents while smoking, and that the incident could have been prevented with proper monitoring. Facility policies reviewed also confirmed the requirement for direct supervision of residents with restricted smoking privileges. The failure to supervise these residents while smoking and to monitor aggressive behavior directly led to the altercation and resulting injury.