Failure to Provide Adequate Supervision Resulting in Resident-to-Resident Altercation
Penalty
Summary
The facility failed to ensure that the resident environment was free from accident hazards and that residents received adequate supervision to prevent accidents, specifically for two residents on the memory care unit. Both residents had moderate cognitive impairment and dementia diagnoses, with care plans identifying risks for physical aggression and the need for close monitoring. Despite these documented risks, the residents were left unsupervised in a common area, which led to a physical altercation. On the day of the incident, both residents were in the television room when one resident pushed the other, leading to a physical fight in which one resident was punched multiple times in the face and head. The nurse assigned to the unit, RN K, was in the nurse's office with the door closed and did not have visual access to the residents. Surveillance footage showed that the altercation lasted for nearly two minutes before RN K exited the office and intervened. During this time, the residents continued to struggle on the floor, resulting in visible injuries, including facial swelling and abrasions. Interviews and record reviews confirmed that the nurse was slow to respond and did not immediately call for assistance. The CNA on duty was occupied in another room and was unaware of the incident until after it occurred. The lack of adequate supervision and delayed intervention allowed the altercation to escalate, resulting in harm to one of the residents. Staff and leadership interviews further corroborated that the nurse's failure to maintain visual supervision and timely response contributed directly to the incident.