Failure to Provide Sufficient Staffing and 1:1 Monitoring Resulting in Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse and neglect, specifically by not providing sufficient staffing and failing to implement required 1:1 monitoring for residents with known behavioral risks. Multiple incidents occurred in both male and female secured locked units, where residents with severe cognitive impairment and behavioral diagnoses engaged in physical altercations resulting in injuries such as head lacerations, skin tears, and hospitalizations. In several cases, residents who were supposed to be under 1:1 supervision were not provided with a dedicated staff member, as required by the facility's own in-service training and policy. On multiple occasions, staff assignments did not include additional personnel for 1:1 monitoring, despite residents being identified as needing such supervision due to aggressive or violent behaviors. For example, one male resident with a history of explosive disorder and severe cognitive impairment physically assaulted another resident, causing a head injury that required emergency room treatment and staples. Another incident involved a resident slapping and injuring a peer while supposed to be under 1:1 monitoring, but no extra staff was assigned, and the monitoring was performed by staff already responsible for the entire unit. Similar failures occurred in the female secured unit, where a resident with traumatic brain injury and dementia physically assaulted two other residents, causing skin tears and facial injuries, again without the required 1:1 supervision being provided. Interviews with staff and review of staffing schedules confirmed that the facility routinely failed to assign additional staff for 1:1 monitoring, instead expecting existing CNAs to rotate or cover both general care and 1:1 supervision, even during night shifts when staffing was further reduced. Staff reported being unable to maintain arm's-length supervision as required, and monitoring sheets were often signed by staff who were simultaneously responsible for multiple units or entire halls. These actions and inactions directly led to resident-to-resident altercations and injuries, as documented in progress notes, investigation reports, and staff interviews.