F0689

D

Failure to Maintain Required 1:1 Supervision for Aggressive Resident Resulting in Resident-to-Resident Assault

Fresno, California Survey Completed on 01-07-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate supervision and maintain an environment free from accident hazards for a resident with known physically aggressive behaviors. Resident 1 had severe cognitive impairment with a BIMS score of 3/15, diagnoses including dementia, anxiety disorders, alcohol abuse, and PTSD, and a documented history of resident-to-resident altercations and aggression toward staff and peers. The resident’s behavior care plan and behavior documentation indicated verbal and physical aggression, including punching, pushing, and grabbing, and required that when the resident ambulated throughout the facility, a designated staff member remain in close proximity at a safe distance to provide immediate redirection and ensure other residents were not placed at risk. Prior to the incident, Resident 1 had been agitated, pacing, yelling, and cursing at staff and peers, and had a history of repeated aggressive behaviors.

On the day of the incident, Resident 1 was supposed to be on 1:1 supervision when out of his room due to his unpredictable and violent behavior. Staff interviews confirmed that Resident 1 was known to become suddenly violent, strike out at staff and residents, and that he required continuous 1:1 supervision for safety, with staff following at a safe distance because he became agitated if they walked next to him. The charge nurse assigned a new CNA (CNA 3), who was still on orientation, to follow Resident 1 and “just watch him” because he was combative. CNA 3 followed Resident 1 for a period until he returned to his room. When lunch trays arrived, CNA 3 left her observation of Resident 1 and began helping other CNAs pass meal trays, leaving Resident 1 unattended in his room despite his need for continuous supervision when out of his room and his known rapid mood changes and aggression.

While Resident 1 was left without direct supervision, he left his room unnoticed, walked to an area near the therapy room and front window, and approached Resident 2 from behind. Resident 2, who was cognitively intact with a BIMS score of 15/15 and had significant physical impairments including bilateral below-knee amputations and osteomyelitis, was seated in his wheelchair near the therapy room. Resident 2 reported that Resident 1 came up very close behind him; he turned his wheelchair around and told Resident 1 not to approach from behind. At that point, Resident 1 punched Resident 2 in the mouth. Documentation and assessments indicated that Resident 2 sustained a split, swollen upper lip with a scratch on the top left side of the lip and bleeding, requiring cleansing with normal saline and application of triple antibiotic ointment. Multiple staff, including the Administrator, DON, Social Services Director, and rehabilitation staff, heard yelling and responded, observing Resident 1 striking Resident 2 in the facial area. The incident occurred at a time when Resident 1 was documented and acknowledged by staff and the care plan to require 1:1 supervision, but the assigned staff member had left the resident unattended to assist with meal tray distribution, resulting in the resident leaving his room undetected and physically assaulting another resident.

Interviews with the Administrator, DON, CNAs, LVNs, and Social Services Director consistently confirmed that Resident 1 had a history of aggressive behaviors, frequent mood changes, and prior altercations with other residents, and that he required 1:1 supervision when out of his room. Staff also confirmed that on the morning of the incident, Resident 1 was agitated and that his usual anti-anxiety medication was not effective. Despite this, the new CNA assigned to follow Resident 1 was not clearly informed that she was responsible for providing continuous 1:1 supervision and left her assignment to help pass lunch trays. The facility’s own Safety and Supervision of Residents policy required that specific interventions, such as supervision levels, be communicated to all relevant staff, that responsibility for carrying out interventions be clearly assigned, and that interventions be implemented correctly and consistently. The failure to ensure that the assigned staff member maintained continuous 1:1 supervision of Resident 1, and the failure to effectively communicate and enforce this supervision requirement, directly led to Resident 1 leaving his room unsupervised and physically assaulting Resident 2, causing injury.