F0689

K

Failure to Prevent Resident-to-Resident Altercations and Inadequate Supervision

Richmond, Virginia Survey Completed on 12-17-2025

Penalty

No penalty information released

Summary

Facility staff failed to provide adequate supervision and care to prevent resident-to-resident altercations and ensure a safe environment for multiple residents. Several residents with known histories of aggressive behaviors, cognitive impairment, traumatic brain injury, or dementia physically assaulted other residents on multiple occasions. In several cases, residents had active provider orders for 1:1 supervision, yet were still able to engage in physical altercations resulting in injuries to others. Documentation revealed that after each incident, care plans and interventions were not reviewed or revised to address the ongoing risks, and there was a lack of consistent documentation regarding the incidents and supervision provided.

In one instance, a resident with a traumatic brain injury and intellectual disability, who had a history of aggression and was under orders for 1:1 supervision, physically assaulted other residents on three separate occasions, causing injuries that required hospital evaluation and treatment. Another resident with severe cognitive impairment and behavioral issues also physically assaulted other residents multiple times, with no evidence of care plan updates or intervention changes following these events. Additionally, two residents in a designated smoking area, both assessed as requiring supervision while smoking, were left unsupervised, resulting in one resident being pulled from his wheelchair and assaulted, sustaining injuries that required medical treatment. Staff and resident interviews confirmed that supervision was not present at the time of the incident, and documentation errors further complicated the facility's response.

Other deficiencies included a resident on 1:1 supervision who was able to strike another resident, and a resident assessed as needing supervised smoking who was observed carrying smoking materials independently through the facility, contrary to safety protocols. Multiple staff interviews confirmed that residents requiring supervision were not being adequately monitored, and that facility policies did not clearly address the requirements for 1:1 supervision or the handling of smoking materials for residents assessed as needing supervision. These failures resulted in harm to residents and placed all residents at risk of abuse and unsafe conditions.

Removal Plan

• Resident #32, #7, #26 is now under 1:1 supervision being in close proximity to ensure staff can deescalate or intervene with any possible altercations.
• Resident #40 will not be allowed to smoke unsupervised.
• Resident #26 will not be allowed to smoke unsupervised.
• A dedicated staff member has been assigned to always monitor residents #40 and #26 during smoking breaks.
• The dedicated staff member has been established to the designated smoking area within a secure part of the facility grounds.
• The facility will educate all staff on the abuse policy.
• The DON or designee will educate on abuse and 1:1, ensuring that staff doing 1:1 are in close proximity to the resident to de-escalate or intervene with any possible altercations and will provide privacy while performing bodily functions outside of the door.
• The DON or designee will conduct an audit of those residents currently on 1:1 to ensure the person assigned is monitoring the patient.
• Nursing staff on all shifts will document any unusual, increased, or change in behaviors, which will be reported and documented in the medical records.
• During clinical review, residents at risk for aggressive behaviors will be determined and appropriate interventions will be put in place.
• Patients who wish to smoke will be evaluated using the Smoking Safety Screen Assessment upon admission and as needed to determine a need for supervision.
• Current residents that smoke will be reassessed using the Smoking Safety Screen Assessment to determine if supervision is required.
• The facility will schedule a staff member to be in the courtyard while smoking occurs.
• The Interdisciplinary Team (IDT) will be educated by the Regional Director of Clinical Services on the policy and procedures to identify abuse.
• IDT will be educated on what a 1:1 entails, which includes maintaining arm's length while inside and outside of the room.
• Anyone providing 1:1 care will be scheduled by staffing, with their relief person for break noted on the schedule.
• Resident on 1:1 will be documented on daily by assigned staff, and this will be collected by the charge nurse.
• Staff will be educated that you may not leave the resident until you have a relief person; you have to remain in close proximity to the resident to ensure staff can deescalate or intervene with any possible altercations while on one-to-one inside and outside of room.
• The Regional Director of Clinical Services will educate the IDT team on the need for supervision for residents identified as requiring supervision while smoking, ensuring all residents requiring supervision are supervised while smoking.
• The DON or designee will create a schedule for supervision of residents that smoke and ensure they are in the smoking courtyard while residents requiring supervision are present.
• This education will be provided to all staff, and no employee will be allowed to work until they are educated, including agency staff.
• A review of resident #32, #7, #26 care plan will be conducted to assess the effectiveness of the interventions and make adjustments.
• The DON or designee will audit residents with 1:1 supervision to ensure staff is remaining in close proximity to the resident to ensure staff can deescalate or intervene with any possible altercations.
• Facility will monitor all residents who have been identified as supervised smokers.
• All supervised smokers will smoke in the designated smoking area that has been established within a secure part of the facility grounds.
• If supervision is deemed necessary, the resident will be supervised by a designated staff.
• The DON or designee will audit residents who are supervised smokers to ensure they are supervised while smoking.