Failure to Maintain Required 1:1 Supervision for Aggressive Resident
Penalty
Summary
The facility failed to protect residents from physical abuse and neglect, specifically by not ensuring continuous one-to-one monitoring for a resident with a documented history of aggressive behavior towards another resident. The resident in question had multiple diagnoses, including frontotemporal neurocognitive disorder and vascular dementia with behavioral disturbances, and was known to display physical and verbal aggression towards others every 1–3 days. Despite repeated incidents—such as attempting to stab a roommate with a utensil, hitting another resident with a broom, and striking a resident in the face—interventions in the care plan were limited to documentation, physician notification, and psychiatric referral as needed. The care plan was updated to reflect the risk, but the resident was removed from 1:1 monitoring following an IDT meeting that did not include the psychiatric nurse practitioner (PNP), who had previously recommended continued 1:1 supervision due to ongoing aggression. The decision to discontinue 1:1 monitoring was made by the IDT, which included the Administrator, DON, and other staff, but excluded the PNP and did not document the information reviewed. Staff interviews revealed that the resident continued to display fixation and aggression towards the targeted resident, and that staff felt 1:1 monitoring was necessary to prevent further incidents. Multiple staff members, including nurses and CNAs, described ongoing altercations and the inability to keep the two residents separated within the secured unit. The psychiatric provider and several staff members expressed concern that removing 1:1 monitoring increased the risk of harm, but their input was not included in the decision-making process. Facility policy required monitoring, prompt reporting, and care plan updates for resident-to-resident altercations, as well as psychiatric consultation and possible transfer if care could not be provided safely. However, the facility did not follow these protocols consistently, as evidenced by the lack of continuous 1:1 monitoring and incomplete interdisciplinary involvement in care planning. The failure to maintain required supervision and to include all relevant providers in care decisions resulted in repeated aggressive incidents and placed residents at risk for harm.