Failure to Provide Adequate Supervision Resulting in Resident Altercation and Injury
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for two residents with severe cognitive impairment and behavioral issues. Both residents had documented histories of wandering, physical aggression, and prior altercations. On the day of the incident, video footage showed one resident entering another's room, leading to a physical altercation in the hallway. The altercation escalated, resulting in both residents falling to the ground, with one sustaining a suspected T4 vertebral fracture and a right periorbital hematoma. At the time, only one CNA was present on the unit, as the nurse had left to obtain medication, leaving the unit unsupervised for 15 to 30 minutes. Interviews with staff revealed that the unit was typically staffed with one nurse and one CNA, and there were times when only one staff member was present, especially when the other left for breaks or other duties. Staff and family members reported that both residents had a history of aggressive behaviors toward each other and required separation to ensure safety. Despite these known risks, the facility did not provide sufficient supervision or implement effective interventions to prevent resident-to-resident altercations. Documentation also indicated that previous altercations had occurred between these residents, but no injuries had been reported until this incident. The care plans for both residents identified their behavioral risks and included interventions such as removing them from situations and diverting their attention. However, these interventions were not effectively implemented at the time of the incident. The lack of adequate supervision and failure to follow established care plan interventions directly contributed to the altercation and resulting injuries. The facility's staffing patterns and supervision practices were insufficient to address the needs of residents with known behavioral risks, leading to a serious incident that resulted in significant injury.