Failure to Consistently Implement One-to-One Supervision Resulting in Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that a resident was protected from physical abuse by another resident due to inconsistent implementation of required one-to-one supervision. According to the facility's abuse prohibition policy and the resident's care plan, one-to-one supervision was mandated for a resident with severe cognitive impairment and behavioral symptoms, including impulsive and combative behaviors. Despite these requirements, documentation and direct observation revealed lapses in supervision, allowing another resident to approach and physically strike the resident under one-to-one supervision. The incident occurred when a cognitively intact resident became agitated by music being played at the nurses' station, removed the speaker, and threw it on the floor. This led to an escalation between the two residents, with spitting and verbal exchanges, followed by the cognitively intact resident striking the other resident in the face multiple times. Witness statements from staff indicated that the assigned nurse aide was present but was unable to prevent the altercation, and the documentation did not consistently demonstrate that one-to-one supervision was effectively maintained at the time of the incident. The resident who was struck sustained a possible nondisplaced nasal fracture and was transported to the hospital for evaluation. Further observation during the survey revealed ongoing noncompliance with the one-to-one supervision policy, as the resident requiring supervision was observed without a staff member in direct line of sight or within reach. Interviews with staff, including the assigned nurse aide and the Director of Nursing, confirmed that one-to-one supervision was required but not consistently implemented. These failures directly contributed to the resident's exposure to physical abuse by another resident.