Failure to Adequately Supervise Resident With Aggressive Behaviors Leading to Two Resident Altercations
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and interventions to manage aggressive behaviors for a resident with a known history of agitation and aggression, resulting in resident-to-resident altercations. Resident 3, who had severely impaired thinking and memory per the admission MDS, had previously resided in the facility and had shown agitated and aggressive behaviors during that prior stay. After readmission, some staff, including a CNA, reported that Resident 3 had a temper, could get angry easily, and had mood swings from happy to angry, especially when they did not get what they wanted. On the date of the incident, Resident 3 first used both hands to grab Resident 2 by the hair and shake them hard in a hallway area. Resident 2, who also had severely impaired cognition, was later assessed and found to have no injuries and no recollection of the event. Approximately 40 minutes after the initial hair-pulling incident, while the Resident Care Manager remained with Resident 3 and was monitoring their behavior, Resident 3 reached out and grabbed Resident 1’s left arm as Resident 1 sat in a wheelchair talking with Resident 2 in the hallway. Resident 1, who had intact cognition, reported that the event happened quickly, that they had not been interacting with Resident 3, and that the forceful grabbing caused their skin to tear and immediate bruising. The resulting skin tear measured 3.5 cm by 3.0 cm, with two bruises measuring 2.0 cm by 2.5 cm and 4.0 cm by 4.0 cm on the left arm. Staff interviews indicated that, despite awareness of Resident 3’s prior history of aggressive behavior and the implementation of close staff supervision after the first altercation, staff were unable to prevent Resident 3 from quickly initiating a second physical altercation that caused injury to another resident.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.