Failure to Supervise Aggressive Resident Results in Immediate Jeopardy
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents involving a resident with known aggressive behaviors. Upon admission, the resident had documented diagnoses of Schizoaffective Disorder, Bipolar Type, Schizophrenia, and Suicidal Ideation, and exhibited severe cognitive impairment. Despite these known risks, the facility did not implement appropriate psychiatric care, enhanced supervision, or reassign vulnerable roommates. The resident repeatedly refused medications, threatened staff, and engaged in escalating aggressive and combative behaviors, including chasing and cornering staff, barricading rooms, and making death threats. Multiple staff interviews revealed that the resident's behaviors were not consistently managed or reported. Nurses and LPNs observed the resident threatening to harm others, barricading himself and others in rooms, and requiring police intervention on more than one occasion. Staff acknowledged that affected roommates and nearby residents were not relocated or provided with additional protection, and interventions were limited to verbal reassurance. Residents reported feeling unsafe, unable to sleep, and fearful of being harmed, with one resident avoiding their room and another being trapped and crying due to fear. Record reviews documented a pattern of aggressive incidents, including threats to kill staff and residents, inappropriate sexual comments, attempts to scald others, and physical altercations requiring emergency services. The facility did not remove environmental risks, such as unsecured fire extinguishers and movable beds, which the resident used to barricade doors. The lack of adequate supervision, failure to implement effective interventions, and insufficient response to escalating behaviors resulted in Immediate Jeopardy and Substandard Quality of Care, directly affecting multiple residents.
Removal Plan
- The Director of Nursing started an all-staff in-service on Abuse/Neglect policy with emphasis on resident psychosocial harm and abuse de-escalation of behavioral episodes and an investigation of psychosocial harm.
- Affected residents care plans were updated to reflect trauma informed care by the Care Plan team.
- The Regional Director in-serviced the Administrator and the Director of Nursing regarding Abuse/Neglect, Investigations of Psychosocial Harm, Behavioral Services, De-escalations and Accidents and Hazards.
- An Emergency Quality Assurance Committee was held with the following staff in attendance: Regional Director, Executive Director, Director of Nursing, MDS Nurse, Business Development Services, Social Services Director, Assistant Director of Nursing, Environmental Services, Maintenance Director and Infection Prevention Nurse.
- Residents #2, #3 and #4's Care Plans were updated to include Trauma Centered care.
- Education was initiated with all facility staff by the Director of Nursing on Abuse and Neglect Policy with emphasis on Resident's psychosocial harm, de-escalation of behavioral episodes and investigation of psychosocial harm. Staff will be educated prior to accepting assignment.
- Education was conducted with the Executive Director and Director of Nursing by the Regional Director of Clinical Services on investigation post behavioral episodes for psychosocial harm of Residents.
- Interview with current Residents with a Brief Interview Mental Status (BIMS) or 10 or greater was conducted by the Social Services Director, Social Services Assistant, and the Assistant Director of Nursing to assess for any psychosocial harm or Incident of trauma.
- Quality Assurance Performance Improvement (QAPI) Committee met. Abuse Neglect Policy, Behavioral Health Policy and Accidents and Supervision Policy was reviewed with no changes made.
- Once Resident #1 exited facility the fire extinguisher was mounted back securely, and the beds were placed with wheels locked to remove barricade risk.
- Resident #1 will not return to the facility until cleared and appropriate safeguards are in place.