F0656

D

Failure to Implement One-on-One Supervision Care Plan Resulting in Resident-to-Resident Altercation

Saginaw, Michigan Survey Completed on 01-15-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement an active care plan intervention for one-on-one supervision for a cognitively impaired resident with a history of agitation and behavioral issues. Resident #103, a 79-year-old with Alzheimer’s, dementia, psychotic disturbances, agitation, and depression, had a BIMS score of 3 and required staff assistance with all ADLs. The resident’s behavioral care plan, dated 10/21/25, specified that the resident would have 1:1 staff supervision for safety, and this intervention had not been discontinued at the time of the incident. On the date of the incident, video review showed that Resident #103 left her room and entered the adjacent room of Resident #106 without being accompanied by staff, despite the active 1:1 supervision care plan.

Resident #106, an 82-year-old with Alzheimer’s, dementia, Parkinson’s, schizophrenia, bipolar disorder, stroke, and agitation, also had a BIMS score of 3 and required assistance with all ADLs. According to the incident report, when Resident #103 entered Resident #106’s room, Resident #106 yelled for her to get out, and Resident #103 scratched him in the face. Video observation showed CNA C seated in the hallway next to both residents’ rooms, using her personal cell phone to text and scroll, with a portable computer positioned in a way that blocked her from the view of the nursing station. During this time, Resident #103 went into Resident #106’s room without intervention from CNA C. Interviews confirmed that Resident #103 was care planned for 1:1 supervision for safety at the time and that this intervention remained active and had not been discontinued, yet it was not being implemented when the resident-to-resident interaction and resulting scratches occurred.