Failure to Provide Adequate Supervision to Prevent Multiple Resident-to-Resident Altercations
Penalty
Summary
The facility failed to ensure adequate supervision to prevent multiple resident-to-resident altercations involving cognitively impaired and behaviorally complex residents. In one incident, a nurse heard a resident with severe cognitive impairment and a history of aggression yell at another resident to get out of his room, followed by observation of the second resident on the floor in the first resident’s room. The nurse then witnessed the first resident kick the second resident twice in the back/shoulder area while staff were attempting to assist the resident from the floor. Both residents had documented histories of aggression toward others, and both had psychiatric and cognitive diagnoses, including traumatic brain injury, dementia, schizoaffective disorder, bipolar disorder, schizophrenia, PTSD, and anxiety. The facility’s own investigation acknowledged that physical contact occurred between the two residents, resulting in a scratch on one resident’s neck, a cut on the other resident’s arm, and reported back pain. In a separate incident, two roommates were involved in a physical altercation after one resident was moved into the other’s room despite staff concerns. One resident, who was described by staff as aggressive and known not to like having roommates, was placed with another resident who was described as nice and who preferred the door open, in contrast to the aggressive resident’s preference for a closed door. Shortly after the room change, the second resident exited the room distressed and reported being hit by the roommate, initially stating they were hit in the face with a hand and also reporting being struck with a bathrobe related to a misunderstanding over clothing. The resident reported feeling unsafe in that room and only feeling safe after being moved, and staff confirmed that they had previously expressed concerns to administration that this roommate pairing would not be a good fit due to the aggressive behaviors of the first resident. Two additional incidents involved a resident with marked cognitive impairment who did not like others entering his room and another cognitively impaired resident who had a behavior of climbing into other residents’ beds, as well as a separate altercation between the same resident and another cognitively impaired resident in a hallway. In the first of these, staff responded to yelling and found one resident partially on the bed and the other resident in a wheelchair holding the first resident’s wrist and making physical contact. In the second, the resident who believed another resident had stolen his items confronted that resident in the hallway, and both residents struck each other in the face after the confrontation escalated. In all of these events, the residents involved had documented cognitive impairments and behavioral histories, and physical contact between residents was observed or confirmed by staff, demonstrating that supervision and monitoring were insufficient to prevent repeated resident-to-resident altercations. The facility’s staffing policy stated that adequate staffing would be maintained on each shift to ensure residents’ needs and services were met, including supervision and monitoring by licensed nurses and CNAs. Despite this, multiple resident-to-resident physical interactions occurred across different dates and units, involving residents with known behavioral issues and cognitive impairments. Staff interviews indicated that some concerns about roommate compatibility and aggressive behaviors were known prior to at least one of the incidents, yet the room assignment proceeded and an altercation followed. The pattern of events described in the report shows that the facility did not provide adequate supervision or environmental management to prevent these resident-to-resident altercations, resulting in physical contact, minor injuries, and distress for the residents involved.
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