Failure to Supervise Aggressive Resident Resulting in Resident-to-Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate supervision and monitoring for a resident with a known history of aggressive behavior, which allowed him to enter another resident’s room and assault her. The aggressive resident had multiple behavior care plans noting severe mental illness, including schizophrenia, psychosis with hallucinations, and bipolar disorder, with documented poor impulse control, lack of sound judgment, and a history of physically abusive behavior when agitated. His care plans included interventions such as administration of psychoactive medications as ordered, behavior tracking, reporting abnormalities to the physician, and daily monitoring and supervision. The medical record documented repeated noncompliance with medications, impaired comprehension, delusions, paranoid and disorganized thought processes, poor self-awareness, and auditory hallucinations, with social services counseling attempts that were not successful in improving his medication compliance. Despite these known risks and documented behaviors, the resident was able to access another resident’s room without effective supervision. The assaulted resident reported that the aggressive resident entered her room, became upset about a milk carton he believed was expired, yelled at her, struck her on the right side of the head with the milk carton, pushed her onto the bed, grabbed her upper arms, and shook her violently. Another resident reported hearing screaming and smacking sounds, then seeing the aggressive resident hitting the victim and intervening by pulling him off and standing between them. A roommate corroborated that the aggressive resident was hitting the victim, and another roommate stated she saw him on top of the victim punching her in the face before other residents and staff intervened. These events demonstrate that the facility did not provide adequate supervision and monitoring to prevent the aggressive resident from entering another resident’s room and engaging in physical and verbal assault, despite his known behavioral risks and documented need for close supervision.
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