Failure to Prevent Resident-to-Resident Abuse and Accidents Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision and a hazard-free environment to prevent accidents and resident-to-resident abuse for all eight residents reviewed. Multiple incidents occurred in which residents with severe cognitive impairments and behavioral issues were not properly monitored, resulting in physical and sexual abuse. For example, one resident with Alzheimer's disease and a history of psychotic disorder was pushed to the floor by another resident, resulting in a fractured toe. Another resident was hit in the head twice by a roommate, and a separate incident involved a resident being slapped in the face from behind by another resident. These events were witnessed by staff, and in some cases, staff were the only ones present on the unit, indicating inadequate staffing and supervision. Further review revealed that residents with known histories of aggression, wandering, and inappropriate behaviors were not consistently provided with the necessary supervision or interventions to prevent altercations. Several care plans documented the need for monitoring, behavior management, and interventions such as 1:1 supervision, but these measures were not always implemented or effective. Staff interviews indicated that there were times when only one CNA was present on the secured unit, and staff expressed concerns that incidents could have been prevented with more personnel. Documentation also showed that some aggressive behaviors were not promptly reported to facility leadership, and there was a lack of communication regarding the transfer of residents to behavioral hospitals following incidents. A particularly severe incident involved a resident with a history of sexually inappropriate behavior who was found sexually assaulting another resident with moderate cognitive impairment. The assaulted resident was confused and did not recall the event, and both residents required medical evaluation. Staff interviews and documentation indicated that the resident with a history of sexual behaviors had previously made inappropriate comments and had engaged in similar behaviors before, but interventions to prevent further incidents were insufficient. The facility's failure to provide adequate supervision and to implement effective interventions placed all residents in the secured unit at risk of injury and harm.