Failure to Provide Adequate Supervision During 1:1 Monitoring Results in Resident-to-Resident Assault
Penalty
Summary
The facility failed to protect a resident from mistreatment and did not ensure adequate supervision of a resident who was on one-to-one (1:1) observation, resulting in a resident-to-resident physical altercation. One resident with a history of anxiety, combative behaviors, and prior incidents of resident-to-resident abuse was placed on 1:1 monitoring following multiple behavioral incidents, including altercations and attempts to remove safety devices. Despite these interventions, the resident was left unattended by the assigned staff member, who left the room to obtain coffee, leaving the resident unsupervised. During this period of unsupervised time, the resident left their room and entered the dining area, where another resident with hemiplegia and hemiparesis was present. The unsupervised resident approached and struck the other resident in the face, knocking off their glasses and using derogatory language. The incident was witnessed by staff and reported by the affected resident, who expressed feeling unsafe and anxious following the event. Facility documentation and interviews confirmed that the staff member responsible for 1:1 monitoring was not present with the resident at the time of the incident, contrary to facility policy and the intended purpose of continuous observation. The affected resident, who was dependent on assistance for activities of daily living due to stroke-related impairments, reported increased anxiety and distress as a result of the altercation. Facility records and staff interviews corroborated that the assigned staff member failed to maintain constant visual supervision, which directly led to the opportunity for the physical assault to occur. The facility's policies on 1:1 monitoring and abuse prevention were not followed, resulting in a failure to protect the resident from mistreatment.