Failure to Supervise Resident with Psychosis Resulting in Resident-to-Resident Abuse
Penalty
Summary
The facility failed to provide adequate supervision and appropriate behavioral health interventions for a resident with a known history of chronic delusions, psychosis, restlessness, agitation, and aggressive behaviors. This resident, who had diagnoses including Schizoaffective Disorder, Bipolar Disorder, and Dementia with Behavioral Disturbance, exhibited impaired cognition and was documented as resistant to care, wandering, and receiving antipsychotic medication. Despite these known risk factors and a history of unpredictable and aggressive behaviors, the facility did not consistently implement or document supervision or individualized interventions to prevent harm to other residents. Two separate incidents occurred in which the resident physically struck other residents on the shoulder. In both cases, the actions were linked to the resident's delusional thinking and psychosis, as evidenced by statements made during investigations and interviews with staff and witnesses. Staff interviews confirmed that the resident's behaviors were unpredictable and that effective prevention would require close or one-to-one supervision when the resident was in common areas with others. However, the facility's records and care plans did not reflect ongoing or routine supervision or specific interventions to address the risk of harm to others, despite the resident's established behavioral history and previous incidents. Facility policies on abuse prevention and behavior management required individualized assessment and intervention for residents with behaviors that could harm themselves or others. However, after the initial incident, there was no documented assessment to determine the appropriate level of supervision needed for the resident, and the care plan was not updated to reflect the physical aggression. The lack of consistent supervision and failure to update care plans or implement effective interventions resulted in repeated incidents of resident-to-resident abuse, as observed and reported by staff and documented in investigative files.