Resident with Dementia Left Unsupervised During Violent Behavioral Outburst
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate supervision and behavioral health services for a resident with major mental illness during a physical and verbal outburst. Resident B, who was moderately cognitively impaired and diagnosed with depression, anxiety, unspecified dementia, and a history of visual hallucinations, resided on a locked dementia unit and used a wheelchair and walker for mobility. On the night of the incident, Resident B approached the nurse’s station from behind where another resident, Resident F, was seated next to an RN. Resident B stated, "I'm going to kill you tonight. I don't need anything to do it; I will strangle you," then attempted to grab the back of Resident F’s chair and pull it backwards, and tried to grab Resident F’s shirt. Staff intervened to move Resident F away from Resident B. As Resident B continued toward staff and Resident F in an intimidating manner, he obtained a colored pencil from behind the nurse’s station desk and advanced toward them. The RN and a CNA then went into a resident’s room directly in front of the nurse’s station and closed the door, leaving Resident B alone and unmonitored at the nurse’s station during his outburst. The room door lacked a window, and no staff remained present to observe Resident B’s actions. While unmonitored, Resident B threw a drink, the phone, and attempted to throw the computer monitor off the desk. Resident B’s care plan, initiated the day before the incident, identified delusions that someone was out to get him and included interventions such as ensuring the resident’s safety and ascertaining potential for harm to self or others. The facility’s dementia aggression/anger policy directed staff to assess and decrease the level of danger for themselves and the resident with dementia, but during this event, staff actions resulted in the resident being left unsupervised during an active behavioral outburst.
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