Failure to Implement One-to-One Monitoring Results in Resident-to-Resident Aggression
Penalty
Summary
The facility failed to implement a care plan intervention of one-to-one monitoring for a resident with a diagnosis of schizophrenia, who exhibited aggressive behaviors such as yelling, verbal aggression, and attempts to strike out at staff. The resident's care plan, developed after previous episodes of aggression and exit-seeking behavior, specifically included one-to-one monitoring as an intervention to minimize these behaviors. However, on the day of the incident, the assigned one-to-one monitoring was not provided, and the only staff present on the smoking patio was an Activities Assistant who was not designated as the resident's one-to-one monitor. As a result of this lapse, the resident was able to approach and punch another resident on the left side of the chest while unsupervised. Interviews with staff confirmed that the one-to-one monitoring assignment was missed, and the intervention outlined in the care plan was not followed. The facility's policy required comprehensive, person-centered care plans with measurable objectives and timeframes, but the failure to implement the specified intervention led to an incident of resident-to-resident aggression.