Failure to Prevent Resident-to-Resident Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect two residents from abuse when both individuals, each with severe cognitive impairment and a history of aggressive behaviors, became involved in a physical altercation. Video footage showed one resident entering the other's room, followed by a struggle in the hallway where both residents fell to the ground. One resident sustained a suspected T4 vertebral fracture and a right periorbital hematoma, while the other had visible bruising. At the time of the incident, only one CNA was present on the unit, as the nurse had left to obtain medication, leaving the unit unsupervised for approximately 15 to 30 minutes. Both residents had documented histories of wandering, physical aggression, and behavioral issues, with care plans indicating the need for interventions to protect the safety of others. Staff interviews revealed that altercations between these two residents had occurred previously, and staff had previously separated them to prevent harm. Despite these known risks, the staffing pattern on the locked memory care unit was typically one nurse and one CNA, and staff reported that this was insufficient to meet the supervision needs of residents with dementia and behavioral challenges. On the evening of the incident, the lack of adequate supervision allowed the altercation to escalate without immediate intervention. Documentation and interviews indicated that the incident was initially reported as an unwitnessed fall, and there was a delay in recognizing and responding to the severity of the injuries. Family members of the residents expressed concerns about the lack of supervision and communication from the facility. The facility's own policies required prompt reporting, investigation, and intervention in cases of resident-to-resident altercations, but these were not effectively implemented, resulting in significant harm to one resident and placing others at risk.