Failure to Provide Ordered One‑to‑One Supervision Resulting in Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to prevent a resident‑to‑resident altercation for a resident who had been ordered for one‑to‑one supervision. Resident 1 was admitted and later readmitted with diagnoses including unspecified affective mood disorder and psychosis, with documentation of severely impaired cognition, dependence on maximal assistance for mobility and ADLs, and lack of capacity to understand and make decisions. The resident’s care plan, initiated on 9/29/2025 and revised on 2/1/2026, identified risk for elopement based on two prior attempts to leave the facility and directed staff to conduct frequent visual checks. A psychiatric narrative note dated 1/17/2026 documented multiple attempted elopements and stated that Resident 1 required close monitoring and was placed on one‑to‑one supervision to ensure safety, with a plan to continue that level of supervision. On 2/1/2026 at approximately 7:55 AM, an altercation occurred between Resident 1 and Resident 2. Progress notes for that date and time indicated that Resident 1 entered Resident 2’s room, Resident 2 pushed Resident 1 out of the room, and both residents grabbed each other. A CNA who was familiar with Resident 1 reported that Resident 1 had mood swings, might have been confused when entering another resident’s room, and that she personally observed Resident 2 push Resident 1 out of her room on that date. Resident 2’s records showed diagnoses of schizophrenia and major depressive disorder, intact cognition, and independence with mobility and ADLs. During interviews and record review, the DON confirmed that Resident 1’s care plan did not reflect the one‑to‑one supervision ordered in the psychiatric note and acknowledged that the one‑to‑one supervision was not provided on 2/1/2026. The facility’s policies on Safety and Supervision of Residents, Comprehensive Person‑Centered Care Plans, and Wandering and Elopements stated that the environment should be as free from accident hazards as possible, that resident safety and supervision to prevent accidents are facility‑wide priorities, that care plans are to be revised as resident conditions change, and that residents at risk for unsafe wandering are to be identified and protected. Despite these policies and the documented need for close monitoring and one‑to‑one supervision, Resident 1 was not under one‑to‑one supervision at the time he entered Resident 2’s room and the altercation occurred.
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