Failure to Prevent Resident-to-Resident Altercation and Unwitnessed Fall Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards and did not provide adequate supervision to prevent incidents and accidents for two of eight residents reviewed. One resident with Alzheimer's disease, impaired memory, and wandering behaviors entered another resident's room and was physically assaulted with a metal wheelchair pedal, resulting in multiple lacerations and a worsening subdural hematoma. The resident who initiated the assault also had Alzheimer's disease, severe cognitive impairment, and a history of aggression, and was known to be territorial about his space. At the time of the incident, only one staff member was present on the secured unit, and the CNA assigned to the unit had left for a break without clear communication, leaving the nurse as the sole supervisor. The nurse was unaware the CNA had left, and the incident was not immediately detected despite audible cues. Another resident with severe cognitive impairment, a history of falls, and dependent on staff for most ADLs experienced an unwitnessed fall from his wheelchair, resulting in a nasal fracture. The resident was found on the floor with bleeding from the nose, and the incident was not observed by staff. At the time, the CNA was on the opposite side of the nurses' station, and the nurse was on the female secured unit, leaving the male secured unit without direct supervision. The resident was identified as high risk for falls, and the care plan included interventions for safe positioning, but these were not sufficient to prevent the fall. Interviews with staff and family members revealed ongoing concerns about inadequate supervision on the secured unit, particularly with increased census and residents exhibiting wandering and aggressive behaviors. Staff reported that one CNA and one nurse were not enough to provide adequate supervision, and there were instances where staff were unaware of each other's whereabouts or when breaks were taken. The facility did not have a specific policy on staffing or supervision for the secured unit, and management acknowledged trends in incidents related to increased census and staffing challenges.