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F0689
D

Failure to Provide Adequate Supervision for Resident with Aggressive Behaviors

Hartford, Connecticut Survey Completed on 05-20-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when the facility failed to provide adequate supervision and prevent accident hazards for a resident with a known history of aggressive behaviors toward others. The resident, who had diagnoses including anxiety and schizophrenia and demonstrated moderate cognitive impairment, had a documented pattern of resident-to-resident altercations. The care plan for this resident included interventions such as every 15-minute checks, medication administration, and staff intervention when agitation escalated. Despite these interventions, the resident was involved in multiple incidents of physical aggression toward other residents, with care plan updates following each event. Monitoring was discontinued by psychiatry shortly before the most recent incident. Another resident, who had severe cognitive impairment, required assistance with mobility and communication, and was on anticoagulant therapy, became the victim of an unwitnessed physical altercation. This resident was struck in the face by the aggressive resident, resulting in a laceration and subsequent hospital admission for a subdural hematoma. The incident was not witnessed by staff, and the facility's documentation indicated that the aggressive resident's monitoring had been discontinued prior to the event. The injured resident required intensive medical intervention, including a craniotomy and embolization, and remained hospitalized at the time of the survey. Interviews and record reviews confirmed that the aggressive resident admitted to hitting others in the past and in this incident. The facility's investigation did not substantiate abuse, citing lack of willful intent, but did not address whether adequate supervision was provided to prevent the injury. The facility's policy on close observation identified risk factors for harm, including impulsivity and impaired judgment, which were present in the aggressive resident. The deficiency centers on the facility's failure to maintain adequate supervision and implement effective interventions to prevent resident-to-resident altercations and resulting injuries.

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