Failure to Prevent Resident-to-Resident Altercation Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with a history of wandering and severely impaired cognition entered another resident's room in the memory care unit. The wandering resident, who had previously been documented as entering other residents' beds, was not being directly supervised at the time. Staff had checked both residents approximately 15 minutes prior to the incident and found them asleep in their respective beds. During a period when staff were assisting another resident, the wandering resident entered the other resident's room, lay down in the bed, and was subsequently startled, resulting in physical contact that caused a nasal fracture to the other resident. The resident who sustained the injury had diagnoses including dementia, osteoporosis, and osteoarthritis, and was noted to be severely cognitively impaired, requiring limited assistance with most activities of daily living. This resident was not coded for behaviors or wandering on the Minimum Data Set (MDS) and had care plan interventions related to impaired memory and communication, but not for wandering or aggressive behaviors. The resident who wandered had a care plan that included interventions for wandering, such as documenting episodes, orienting the resident, and providing familiar objects, but was also not coded for wandering or behaviors on the MDS. The incident was discovered when the injured resident was found in the doorway, bleeding from the nose and mouth, and reported being hit by another resident. The staff member assigned to both residents responded immediately upon hearing the call for help. The investigation revealed that the wandering resident had a pattern of entering other residents' rooms and beds, and that staff did not witness the incident as it occurred during a lapse in direct supervision. The event resulted in a closed fracture of the nasal bone for the injured resident, who required hospital evaluation.