Failure to Provide Adequate Supervision in Memory Care Unit Resulting in Resident Altercation
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for residents in one of its memory care units. On the date of the incident, only one CNA was present in the memory care unit while the other staff member was absent. During this time, the CNA was occupied in another resident's room assisting with morning care, leaving the remaining residents in the dining area unsupervised. As a result, two residents engaged in an altercation, during which they were observed swatting and slapping at each other's hands. The CNA intervened upon noticing the incident and separated the residents, after which a nurse assessed both individuals and found no injuries. One of the residents involved had a history of Alzheimer's disease, dementia, schizoaffective disorder, muscle weakness, impaired vision, and repeated falls. This resident was severely cognitively impaired, used a wheelchair for mobility, and was dependent on staff for most activities of daily living. The other resident had a history of cerebral infarction, schizophrenia, gait abnormalities, and lack of coordination, with moderate cognitive impairment and a documented history of physical behavioral symptoms directed toward others. Both residents were considered elopement risks and resided on the secured memory care unit due to their behavioral and safety needs. Interviews with staff, including the CNA, RN, DON, and interim administrator, confirmed that there was only one staff member present in the memory care unit at the time of the incident. Staff acknowledged that the unit typically required two staff members due to the residents' behavioral challenges and supervision needs. The facility's policy for the secured unit emphasized the importance of providing a safe and structured environment for residents at risk of elopement or harm due to cognitive impairment. However, on the day of the incident, the lack of adequate staffing and supervision directly led to the altercation between the two residents.