Inadequate Supervision During Mealtime Leads to Resident Altercation
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents during a mealtime in the dining room, resulting in a physical altercation between two residents. On the specified date, only one staff member was present in the dining room, despite the facility's policy and staffing sheet requiring three staff members to be present for each mealtime. The sole staff member, a Kentucky Medication Aide, was unable to leave the dining room to seek additional help when a resident began a verbal altercation with another resident, which escalated to physical contact. The staff member separated the residents but could not maintain supervision of both while also performing other duties, leading to one resident hitting the other with a sandwich and causing emotional distress. Interviews with staff revealed confusion and lack of communication regarding dining room assignments, with some staff unaware of their scheduled responsibilities and others leaving their shifts without coverage. The Activities Director admitted to forgetting to schedule a replacement for an absent staff member, and the Director of Nursing stated there was no designated person responsible for ensuring staff were present according to the schedule. The Administrator and other staff acknowledged that having only one staff member present was insufficient to ensure resident safety and prevent altercations, confirming a failure to follow established supervision protocols.