Failure to Provide Adequate Supervision and 1:1 Monitoring Leads to Resident Injuries
Penalty
Summary
The facility failed to ensure that residents received adequate supervision and assistance devices to prevent accidents, specifically in relation to resident-to-resident altercations on two secured units. Multiple incidents occurred where residents with known behavioral issues and severe cognitive impairment engaged in physical altercations, resulting in injuries such as head lacerations, skin tears, and hospitalizations. In several cases, residents who were supposed to be on 1:1 monitoring did not have a designated staff member assigned to them, as required by the facility's own in-service training and staffing protocols. Instead, existing staff were expected to rotate or cover 1:1 monitoring in addition to their regular duties, leading to lapses in supervision. On the male secured locked unit, one resident with a history of explosive disorder and severe cognitive impairment physically assaulted another resident who had wandered into his room, causing a head injury that required emergency room treatment and staples. The same resident later assaulted a different resident, resulting in a fall and a skin tear. Despite care plans indicating the need for 1:1 supervision, staffing records and interviews confirmed that no additional staff were assigned for this purpose, and the two CNAs on duty were responsible for supervising all residents on the unit as well as providing 1:1 monitoring. Staff interviews corroborated that it was common practice for no extra staff to be provided for 1:1 monitoring, even when required. Similar deficiencies were observed on the female secured unit, where a resident with traumatic brain injury and severe cognitive impairment physically assaulted two other residents, causing skin tears and facial injuries. Again, although 1:1 monitoring was indicated after the first incident, staffing records showed that only one CNA was present for the entire unit, and no additional staff were assigned for 1:1 monitoring. Staff interviews revealed that it was rare for a third CNA to be sent for 1:1 monitoring, and that CNAs often had to rotate the responsibility among themselves while still supervising the rest of the unit. The lack of adequate supervision and failure to follow established protocols for 1:1 monitoring directly contributed to repeated resident-to-resident altercations and injuries.