Failure to Provide Adequate Supervision and Prevent Resident-to-Resident Altercation
Penalty
Summary
The facility failed to provide adequate supervision and assistance devices to prevent accidents for two residents on the memory care unit. One resident with severe cognitive impairment and a history of wandering entered another resident's room during the night. This resident, who had diagnoses including Alzheimer's disease, schizoaffective disorder, and psychosis, was known to wander and had previously been redirected by staff when found in other residents' rooms. On the night of the incident, the resident wandered into another resident's room at approximately 4:00 a.m., resulting in a physical altercation. The resident sustained injuries including skin tears, a raised area on the forehead, and a laceration to the upper lip. The other resident involved, who had moderate cognitive impairment and a history of behavioral issues, reported defending himself and was found with blood on his hand. There was no incident report regarding the injuries, wandering, or altercation for either resident in the facility's records for that month. Staff interviews revealed that only two CNAs and one nurse were assigned to the memory care unit during the night shift, despite a significant number of residents with wandering behaviors. Staff reported that it was common for residents to wander into others' rooms and that redirection was frequently required. On the night of the incident, one CNA left her assigned hall to assist on the other side, leaving one area unattended. Staff also indicated that there was no additional staff assigned to monitor residents when two staff members were required to provide care elsewhere. The Director of Nursing and other staff stated that the staffing pattern was considered sufficient, but acknowledged that additional help was sometimes needed due to the high number of residents who wander. The facility's policies required the Director of Nursing or designee to evaluate staffing needs based on resident acuity and to provide additional staff or training if current levels were insufficient. However, prior to the incident, there was no evidence that interventions or increased supervision were implemented for residents at risk of wandering or altercations. The lack of adequate supervision and failure to implement appropriate interventions led to an Immediate Jeopardy finding by surveyors, as the facility did not ensure the safety of residents with known wandering and behavioral risks.