Failure to Protect Residents from Abuse Due to Inadequate Supervision of Aggressive Resident
Penalty
Summary
The facility failed to protect residents from abuse when a resident with severe dementia and a history of agitation, wandering, and physical aggression was not provided with increased supervision despite escalating behaviors. This resident exhibited daily physical behaviors toward others, including hitting, kicking, and attempting to bite both staff and other residents. On the day of the incident, the resident was observed wandering into multiple resident rooms, displaying aggression, and was repeatedly redirected by staff without success. Staff interviews and progress notes documented that the resident was agitated and combative throughout the day, with multiple unsuccessful attempts to manage the behaviors. Despite the resident's known behavioral risks and a care plan that referenced interventions for redirection and monitoring, the interventions were not individualized and did not address the specific aggressive behaviors toward others. The care plan also did not include increased supervision or one-on-one monitoring, even as the resident's behaviors escalated. Staff statements confirmed that no staff member was specifically assigned to provide one-on-one supervision, and staff were unable to continuously monitor the resident due to other duties. The resident was able to access other units and resident rooms, leading to an incident where the resident entered another resident's room, resulting in a physical altercation. During the altercation, the resident entered another resident's room, and after the other resident fell, began hitting and kicking the resident on the floor. Staff responded and separated the residents, but the lack of increased supervision allowed the incident to occur. The facility's failure to implement individualized interventions and provide adequate supervision for a resident with escalating aggressive behaviors resulted in a failure to protect residents from abuse, as required by facility policy and regulatory standards.