Failure to Provide Adequate Supervision for Resident with Aggressive Behaviors
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and maintain a safe environment for a resident with severe cognitive impairment and a history of physical aggression on a secured dementia unit. The resident, diagnosed with Alzheimer's dementia and other behavioral disturbances, was involved in multiple resident-to-resident altercations, including physical and verbal incidents, despite documented behavioral care plans and interventions. The care plan noted the resident's tendencies to wander, enter other residents' rooms, and display aggressive behaviors, but interventions such as STOP sign banners and redirection were not consistently effective. Multiple reports submitted to the Health Care Facility Reporting System documented repeated incidents where the resident entered other residents' rooms, resulting in altercations and injuries, including lacerations and bruises. Staff interviews confirmed that the resident frequently removed STOP sign banners and entered rooms despite attempts to redirect or deter these behaviors. Staff also reported that the resident required two caregivers for personal care due to aggression and that there was no specific person assigned to supervise the resident when staff were occupied elsewhere. Direct observation by the surveyor revealed that the resident was left unsupervised in the dining/day room, which was not visible from the nurses' station and had areas not easily monitored by staff. During this time, the resident was seen pushing chairs, removing tablecloths, and approaching other residents without staff intervention. Interviews with staff and a psychiatric nurse practitioner confirmed that the resident should not have been left unsupervised, and that current interventions were insufficient to prevent further incidents, placing both the resident and others at risk for harm.