Failure to Provide Adequate Supervision Resulting in Resident Altercation
Penalty
Summary
The facility failed to provide adequate supervision to prevent an altercation between two residents, both of whom were in wheelchairs and located near the nursing station. One resident, diagnosed with schizoaffective disorder, borderline personality disorder, and bipolar disorder, was sitting in her wheelchair in the hallway. Another resident, with diagnoses including encephalopathy, sepsis, and dementia, attempted to pass but was unable to due to limited space. The second resident reached out and pushed the first resident's wheelchair forward in an attempt to get by. This action startled the first resident, who reacted impulsively by reaching back and making contact with the second resident's arm. Staff immediately intervened and separated the residents. Both residents were assessed, and no injuries were noted. Interviews with staff and the residents confirmed that the incident occurred as described, with the first resident expressing that she was startled and did not intend to harm the other resident. Both residents were noted to be cognitively intact according to their most recent BIMS scores and had no prior incidents with each other or other residents. The facility's policy on safety and supervision emphasizes individualized supervision based on assessed needs and environmental hazards, but in this instance, the supervision provided was insufficient to prevent the altercation.