Failure to Prevent Resident-to-Resident Incidents and Inconsistent Fall Prevention
Penalty
Summary
The facility failed to provide adequate supervision to prevent two physical resident-to-resident incidents involving three residents. One incident occurred when a resident removed a chair from the hallway for a guest, which another resident believed was their personal chair. This misunderstanding escalated into a verbal altercation and resulted in one resident kicking the other in the ankle. The incident was brought to staff attention by another resident, not by staff, and initial assessments found no injury, though mild pain and swelling were later noted. The care plan for the resident who kicked did not address their belief about the chair or include follow-up interventions related to this behavior. A second incident involved the same resident making physical contact with another resident after a perceived invasion of personal space, again related to the chair outside their room. Staff and documentation confirmed that the chair was a contributing factor in both incidents, but the issue was not addressed prior to the events. Additionally, the facility failed to consistently implement fall prevention interventions for a resident with a history of multiple falls. The resident, who had moderate cognitive impairment and was at high risk for falls, was observed using a wheelchair with an anti-roll back device that was not functioning properly. The device's lever was repeatedly found in a nonfunctional position, and the wheelchair brakes were not locked during multiple observations. Staff, including nurses and CNAs, were seen interacting with the resident but did not address the malfunctioning device. The resident's medical records documented several falls, with root causes identified as failure to lock the wheelchair. Interventions such as the anti-roll back device were recommended, but there was no evidence of follow-up or adjustment in the care plan after subsequent falls. Behavioral tracking logs for the involved residents were blank, and there was no targeted behavior tracking or documentation of interventions for behaviors such as swearing or invading personal space. Staff interviews confirmed that expectations for ensuring safety devices were in place and functioning were not consistently met. The facility's policy required identification, evaluation, and implementation of interventions to reduce hazards, but these processes were not effectively carried out for the residents involved in the incidents and falls.