Failure to Prevent Resident-to-Resident Altercations Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure that multiple residents received adequate supervision to prevent accidents and abuse, resulting in a series of resident-to-resident altercations. Several residents with severe cognitive impairment and behavioral issues, including wandering and aggression, were involved in repeated incidents where they entered each other's rooms, leading to physical altercations. For example, one resident with dementia and wandering behaviors entered another resident's room and began rummaging through personal belongings, which escalated into a physical fight resulting in minor injuries. In another instance, a resident with a history of wandering and aggression entered a peer's room, leading to a confrontation where one resident was pinned against the wall and struck in the face, causing visible injuries. The report documents that the care plans for these residents identified their behavioral risks, such as wandering and aggression, and included interventions like redirection, monitoring, and structured activities. However, the facility did not consistently implement or update these interventions following incidents. Staff interviews revealed that at times, only one CNA was present on the secure unit, and supervision lapses occurred when staff were occupied with other residents or on break. This lack of adequate supervision allowed residents with known behavioral issues to interact unsupervised, resulting in further altercations and injuries. Additionally, the facility did not review or update care plans or implement new interventions after repeated incidents, even when residents continued to display aggressive or wandering behaviors. The report details multiple occasions where residents were left unsupervised, leading to further physical altercations, including instances of inappropriate sexual contact and repeated physical abuse. These failures were observed through record reviews, staff and resident interviews, and direct observation, demonstrating a pattern of inadequate supervision and failure to prevent resident-to-resident abuse and accidents.