Failure to Maintain Adequate Supervision for Aggressive Resident
Penalty
Summary
The facility failed to implement and maintain adequate safety monitoring interventions for a resident with a known history of aggressive behaviors, resulting in multiple incidents where other residents and staff were harmed or placed at risk. The resident in question, a 35-year-old with diagnoses including autism, schizophrenia, anxiety, and developmental delays, was non-verbal, ambulatory, and required supervision for safety due to aggressive behaviors such as throwing items, scratching, and hitting others. The care plan specified the need for a 1:1 sitter, initially provided by the family and later by the facility, but this intervention was inconsistently implemented, particularly during the night shift. Multiple incidents occurred as a result of lapses in supervision. One resident reported being physically attacked in the therapy gym, while another described being followed into her room and nearly attacked after the aggressive resident was left unsupervised. Staff interviews confirmed that the 1:1 sitter was not consistently assigned, especially during the night shift, despite ongoing aggressive behaviors. Staff members also reported being attacked, with one CNA sustaining injuries severe enough to require medical leave. Another resident was scratched on the face during an unsupervised period at night, and staff acknowledged that the aggressive resident's behaviors were unpredictable and difficult to redirect. Facility leadership, including the ADON and DON, acknowledged that the removal of 1:1 supervision during the night shift was a contributing factor to the incidents. Documentation showed that the resident continued to display aggressive behaviors during the night, even after the sitter was removed from that shift. The facility's own policy required continued 1:1 supervision until dangerous symptoms were reduced and aggressive acts minimized, but this protocol was not followed, leading to harm to both residents and staff.