Failure to Adequately Supervise Resident With Psychiatric and Behavioral History, Resulting in Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and protection from abuse for one resident when another resident physically struck him. A resident with depressive disorder and an intact BIMS score of 14/15 reported that while he was sitting in the hallway minding his own business, his former roommate suddenly approached and hit him on both sides of his head before he could react. A licensed nurse and a CNA both described that the aggressor resident walked toward the victim near the North Nurses Station and hit him in the face, with the licensed nurse stating she saw the aggressor hit the victim twice on the face before she could intervene. The Social Service Director reported that the victim sustained a scratch and redness on the right cheek as a result of being hit. The aggressor resident had been admitted with schizophrenia and depression and had documented auditory and visual hallucinations, including hearing voices and seeing snakes and the devil, as well as a care plan noting potential mood problems with racing thoughts, increased irritability, agitation, and hyperactivity. Staff interviews indicated that this resident had a history of shouting at staff, lunging at staff, and having verbal outbursts, including calling staff devils and talking about snakes. CNAs reported that in the weeks prior to the incident, the resident, who had previously been quiet, became very talkative, expressed delusional beliefs about the other resident having guns and being a bad person, did not want to return to his room, and was observed becoming mad and aggressive. The facility was aware of the aggressor resident’s serious mental illness, as evidenced by a positive PASRR Level 1 screening requiring a Level 2 mental health evaluation and a Level 2 individualized determination report listing services and supports to address mental health needs. The Director of Nursing acknowledged awareness of the resident’s psychiatric diagnosis on admission and stated that the goal was resident safety and that altercations could make residents feel unsafe, fearful, or scared. Despite the known behavioral history, hallucinations, and escalating behaviors, the incident occurred in a common area near the nurses’ station where the aggressor resident was able to approach and hit the other resident before staff could prevent the assault, contrary to the facility’s abuse prevention policy requiring identification, assessment, care planning, and monitoring of residents with behaviors that might lead to conflict.
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