Failure to Supervise Group Activity Resulting in Resident-to-Resident Altercation
Penalty
Summary
The facility failed to provide adequate supervision during a group activity involving five residents in the dayroom after dinner, resulting in a physical altercation between two residents. The incident began with an argument and escalated when beverages were thrown, followed by one resident punching another, who then retaliated. The altercation was not witnessed by staff but was captured on video, which was reviewed by the Administrator the following day. At the time of the incident, no staff were present in the dayroom, and the activity was unsupervised. As a result of the altercation, one resident sustained bruising and a laceration on the bridge of her nose, while the other complained of pain in her eye and jaw and had a scratch on her arm. Both residents were transferred to the hospital for evaluation and treatment. The facility's investigation substantiated that a resident-to-resident physical altercation had occurred. The records indicated that the group activity included residents with varying levels of cognition and behavioral issues, yet no supervision was provided during this time. Interviews with staff and the Social Services Director confirmed that there were no activities staff present after dinner, and residents who remained in the dayroom for independent activities were left unsupervised. Staff were occupied with other duties, such as passing medications and assisting residents to bed. The facility did not have an Activities Director at the time, and there was no plan in place to supervise residents during evening hours, despite the presence of residents with dementia and behavioral concerns.