Failure to Supervise and Monitor Residents with Dementia Resulting in Resident-to-Resident Altercation
Penalty
Summary
The facility failed to ensure adequate supervision and monitoring of residents with dementia and wandering behaviors, resulting in a resident-to-resident altercation that caused injury. One resident with severe cognitive impairment and a history of wandering was not properly observed or redirected, despite physician orders to monitor and document behaviors every shift. The resident's care plan identified wandering and impaired safety awareness, but documentation of behavioral monitoring was incomplete, and there was no evidence that staff consistently followed the monitoring protocol. Progress notes indicated multiple incidents of the resident entering other residents' rooms, exhibiting agitation, and being difficult to redirect prior to the altercation. An incident occurred in which the resident with wandering behaviors entered another resident's room, leading to a physical altercation where the resident bit another resident's forearm, resulting in a skin tear and bruising. The injured resident, who also had severe cognitive impairment, required wound care and was assessed for further injury. Documentation showed that the injured resident complained of pain and received treatment as ordered by the physician. Observations confirmed the presence of a healing wound on the resident's forearm following the incident. Interviews with staff revealed that the facility did not have a policy regarding resident behavior and wandering prevention. Additionally, the care plan for the resident who was injured was not updated following the increase in wandering and agitation behaviors observed in the other resident. The lack of adequate supervision, incomplete documentation, and failure to update care plans contributed to the occurrence of the altercation and subsequent injury.