Failure to Assign One-to-One Monitoring Results in Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from abuse when a resident with a history of aggressive behaviors and a care plan requiring one-to-one monitoring was not assigned dedicated staff for supervision. The resident in question had diagnoses including schizophrenia, moderate cognitive impairment, and exhibited physical aggression such as kicking, hitting, and pushing. Despite care plan interventions specifying one-to-one monitoring and nursing notes indicating the need for constant supervision, the facility did not assign a staff member to provide this level of monitoring. As a result, the resident was left unsupervised on the smoking patio, where he punched another resident on the left side of the chest. The incident was witnessed by an activities assistant, who was present to provide smoking supplies and general supervision but was not assigned as the one-to-one monitor for the aggressive resident. Interviews with staff confirmed that the assignment for one-to-one monitoring was missed, and the Director of Nursing acknowledged that a dedicated one-to-one staff member could have potentially prevented the incident. Both residents involved had schizophrenia, but the victim had intact cognition and required only supervision or touch assistance for activities of daily living. The facility's policy stated that residents should not be subject to abuse by anyone, including other residents.