Failure to Prevent Resident-to-Resident Physical Altercation Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and prevent accident hazards for two residents, resulting in one resident being struck by another. On the night of the incident, a resident with a history of blindness, schizophrenia, bipolar disorder, and nicotine dependence became agitated after being denied the opportunity to smoke outside of designated hours. The certified nursing assistant (CNA) attempted to calm the resident and prevent him from getting up due to his fall risk, but did not notify the registered nurse (RN) of the resident's escalating agitation. Another resident, who had blindness in one eye, diabetes, and major depressive disorder, observed the situation and believed the agitated resident was going to harm the CNA. Acting on this belief, the second resident moved in his wheelchair and struck the agitated resident on the jaw. The incident was witnessed by staff, and the two residents were separated. The struck resident experienced jaw pain and required an x-ray, which showed no fracture. Interviews and record reviews confirmed that the facility's staff did not provide adequate supervision to prevent the altercation. The care plan for the agitated resident required monitoring for unsafe smoking practices and immediate notification of the charge nurse if the smoking policy was violated, but this was not followed. The facility's policies also required staff to protect residents from abuse, including resident-to-resident physical aggression, but these measures were not effectively implemented during the incident.