CNA Failed to Supervise Residents, Resulting in Resident-to-Resident Altercation
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) demonstrated the necessary competency and skill set to care for residents as required by federal regulations. Specifically, an incident occurred in which one resident entered the dining room and grabbed another resident's arm, resulting in a resident-to-resident altercation. At the time of the incident, the CNA assigned to the dining room was present but did not prevent the altercation from occurring. Video footage reviewed during the facility's investigation confirmed that the CNA did not fulfill their job duties to maintain resident safety, as residents are not to be left unsupervised in the dining room. The facility's job description for CNAs includes requirements to comply with workplace safety policies and to carry out essential job functions, which encompass ensuring resident safety. The failure of the CNA to supervise and intervene appropriately in the dining room directly led to the incident, placing residents' safety at risk. The deficiency was identified through interviews and record reviews conducted by the facility's Administrator and Director of Nursing.
Plan Of Correction
Signed POC and Evidence is attached: 2567 POC 1DEC1D-H1 How corrective action will be accomplished for those residents found to have been affected by the deficient practice: Two residents were found to be affected by the deficient practice. Care plans have been updated for both residents. Care plan established for Resident 1 to dine in SCU dining room away from Resident 2 dining in DCU. First and Final Write-up will be issued to responsible CNA A for failing to meet job performance standards and not maintaining established care plan for Resident 1. Resident 1 referred to mental health services. Resident 1 underwent medication review with pharmacist. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: No other residents were found to be affected by the deficient practice. Residents residing in the DCU or those who dine in the DCU had the potential of being affected by the deficient practice. DCU staff were in serviced on Redirecting Residents with Behaviors. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: Resident 1 will eat all meals in the SCU dining room with supervision. How the facility plans to monitor its performance to ensure that the solutions are sustained: Final Write-up delivered to CNA A, follow-up review scheduled on 1/30/2026, 1:1 education delivered to CNA A. DSD will perform sections of the CAN competency check with CNA A weekly for 1 month, followed by 2 times per month for 2 months. Dates when corrective action will be completed: 1/30/26 No other residents were found to be affected by the deficient practice. Residents residing in the DCU or those who dine in the DCU had the potential of being affected by the deficient practice. DCU staff were in serviced on Redirecting Residents with Behaviors. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: Resident 1 will eat all meals in the SCU dining room with supervision. How the facility plans to monitor its performance to ensure that the solutions are sustained: Final Write-up delivered to CNA A, follow-up review scheduled on 1/30/2026, 1:1 education delivered to CNA A. DSD will perform sections of the CAN competency check with CNA A weekly for 1 month, followed by 2 times per month for 2 months. Dates when corrective action will be completed: 1/30/26