Failure to Provide Adequate Supervision and Prevent Accident Hazards
Penalty
Summary
Facility staff failed to provide adequate supervision and address accident hazards for three residents with significant cognitive and behavioral impairments. One resident with severe cognitive impairment and a history of bipolar disorder and dementia was repeatedly observed by staff to play with and ingest fecal material. Despite these behaviors being known to multiple CNAs and an LPN, there was no evidence in the care plan or clinical record of interventions or supervision strategies to prevent this behavior, nor was there documentation of the incidents or communication of a plan to staff. Another resident with dementia, bipolar disorder, and depression exhibited ongoing aggressive and disruptive behaviors, including grabbing another resident by the shirt collar, entering other residents' rooms, and engaging in physical altercations. Although staff and administration were aware of these behaviors, interventions such as room changes and one-on-one supervision were not implemented until after multiple incidents had occurred. Staff interviews confirmed that supervision was inconsistent, and there was no documentation of decision-making regarding supervision or timely implementation of interventions to prevent further incidents. A third resident was involved in multiple resident-to-resident altercations, including slapping, hitting, and entering other residents' rooms and beds. The care plan only indicated to monitor the resident closely, but staff interviews revealed that supervision was insufficient, especially when staffing levels were low. The clinical record documented repeated incidents of aggression and inappropriate room entry, with staff acknowledging the difficulty in providing adequate supervision to prevent these events. The facility's policy required individualized safety interventions and communication to staff, but these measures were not consistently documented or implemented for the residents involved.