Failure to Maintain 1:1 Supervision Resulting in Resident-to-Resident Physical Abuse
Penalty
Summary
A resident with unspecified dementia and severe cognitive impairment was placed on continuous one-to-one (1:1) observation due to behaviors such as wandering, entering other residents' rooms, hitting staff, and attempting to leave the facility. The care plan and staff interviews confirmed that the expectation was for a staff member to be with the resident at all times to ensure safety and prevent incidents. Despite these interventions, the resident was left unattended and wandered into another resident's room. During this time, another resident became agitated and punched the resident in the chest. Multiple staff members, including CNAs and nurses, confirmed that the resident on 1:1 observation did not have a staff member present at the time of the incident, which was contrary to facility policy and the resident's care plan. Facility records and staff interviews indicated that the 1:1 observation was implemented specifically to prevent such incidents, and that staff were aware of the procedures requiring continuous supervision. The failure to maintain 1:1 supervision resulted in the resident being physically abused by another resident, as documented in care plans, progress notes, and staff statements.