Failure to Prevent Resident-to-Resident Altercation Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure that the resident environment was as free from accident hazards as possible and did not provide adequate supervision to prevent accidents, resulting in a physical altercation between two residents. One resident, who had a history of Alzheimer's disease, dementia, moderate cognitive impairment, and documented behavioral symptoms including physical aggression, was sitting at a dining room table with an LVN. Despite being known for behavioral triggers such as loud noises and paranoia about personal space, the resident was not on 1:1 supervision at the time. The resident got up from the table, approached another resident, and punched him in the face, causing the second resident to fall against the wall and then to the ground. The second resident, who also had Alzheimer's disease, dementia, moderate cognitive impairment, and a history of poor balance and unsteady gait, sustained a facial laceration and a fractured hip as a result of the fall. The incident was witnessed by staff who were present in the dining room, but the supervision provided was not sufficient to prevent the altercation. Staff interviews revealed that although they were aware of the first resident's behavioral history and triggers, and all staff were responsible for monitoring residents, the level of supervision was not adequate to prevent the incident. The care plan for the aggressive resident included interventions for behavioral management, but these were not effectively implemented at the time of the event. The deficiency was identified as past non-compliance and was determined to have placed residents at risk of harm and/or severe injury. The incident led to Immediate Jeopardy, as the lack of adequate supervision and failure to maintain a safe environment directly resulted in a resident sustaining significant injury. The facility's policies required staff to monitor residents with behavioral health needs and to provide person-centered care, but these measures were not sufficiently executed to prevent the altercation and subsequent injury.