Failure to Provide Required Supervision Resulting in Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident with a history of wandering from physical abuse by not providing required 1:1 supervision as outlined in the resident's care plan. The resident, who had diagnoses including paranoid schizophrenia, dementia, and cognitive communication deficits, was known to wander into other residents' rooms and had been identified as at risk for wandering. Despite this, staff did not consistently implement 1:1 monitoring, and the resident was able to enter another resident's room unsupervised. Another resident, who had a documented history of aggressive behavior, schizoaffective disorder, antisocial personality, and amnestic disorder, was residing in the same secured unit. This resident had previously exhibited poor impulse control and had a history of physically assaulting peers. On the day of the incident, staff were not actively monitoring the hallways, and both residents were only being checked every two hours, rather than being under continuous observation as required for the wandering resident. As a result of these lapses, the wandering resident entered the aggressive resident's room, leading to a physical altercation. The aggressive resident struck the wandering resident in the face, causing injuries including a right cheek abrasion, orbital discoloration, nosebleed, and a scalp hematoma. The incident was unwitnessed, and staff only became aware after hearing yelling. Interviews with staff confirmed that the required 1:1 supervision was not in place at the time of the incident, and that the facility's policy to protect residents from abuse was not followed.