Failure to Provide Supervision Resulting in Resident-to-Resident Altercation
Penalty
Summary
The facility failed to provide adequate supervision to a resident with a known history of schizophrenia, anxiety, and aggressive behaviors, as outlined in the resident's care plan. The care plan specified that the resident was at risk for aggression and unsafe behaviors, with documented incidents of striking peers due to paranoid ideation. Interventions included 1:1 supervision during meals and restricted access to common areas unless accompanied by staff and deemed psychiatrically stable. However, the care plan did not specify the duration of these interventions, and there was no documented behavioral evaluation or interdisciplinary team note addressing the discontinuation of 1:1 supervision prior to the incident. On the day of the incident, the resident was not under 1:1 supervision and was able to access the patio area where another resident was present. The unsupervised resident struck the other resident in the face without provocation, resulting in significant injuries including a laceration under the left eye, a skin tear on the eyelid, and a displaced fracture of the left nasal bone. The injured resident required transfer to an emergency department for further evaluation and treatment. Staff interviews confirmed that the resident who initiated the altercation had a history of unpredictable aggression, paranoia, and auditory hallucinations, and that staff had difficulty identifying specific triggers for the aggressive behavior. Facility staff, including the administrator and mental health workers, acknowledged that the resident was no longer on 1:1 supervision based on staff discretion, without a physician's order or documented interdisciplinary review. The facility's policy required comprehensive care planning and revision as needed based on changes in the resident's condition or behavior, but there was no evidence that the care plan was appropriately updated or that supervision protocols were maintained in accordance with the resident's assessed needs. This lapse in supervision directly led to the resident-to-resident altercation and subsequent injury.