Failure to Prevent Resident-to-Resident Abuse and Neglect Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect two residents from abuse and neglect, as required by its own policies and regulatory standards. One resident with Alzheimer's disease and severe cognitive impairment was care planned to be closely observed when not in their room due to a history of behavioral issues, including wandering and aggression. Despite this, the resident was left unattended on multiple occasions, resulting in two separate incidents: in one, the resident struck another resident with their walker, and in another, the same resident was sprayed in the face with hot sauce by a different resident. Staff interviews confirmed that the resident was known to wander and required close supervision, but it was unclear whether this supervision was consistently provided. In the first incident, the resident with behavioral disturbances struck another resident, who then retaliated by hitting back. Both residents were found outside their assigned units, and staff responded by separating them. Documentation and staff interviews indicated that the resident who initiated the altercation had a pattern of striking others with their walker or running into them in the hallway. The care plan specifically called for close observation when the resident was not in their room, but this was not effectively implemented, allowing the altercation to occur. In the second incident, the same resident was found near another individual they were supposed to avoid due to a prior incident. Before staff could intervene, the other resident sprayed hot sauce into the resident's eyes. Staff responded by flushing the resident's eyes and moving them back to their unit. Interviews with staff revealed that the resident's tendency to wander and the need for close observation were well known, yet lapses in supervision allowed these incidents to happen. The facility's policy required identification and intervention in situations likely to result in abuse or neglect, but these measures were not adequately enforced.