Failure to Adequately Supervise Residents Leading to Resident-to-Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and prevention of accident hazards during an interaction between two residents in the dining/dayroom. One resident with Alzheimer’s disease, major depressive disorder, anxiety disorder, severely impaired cognition (BIMS score of 7), and a history of agitation and verbal outbursts entered the dining room where another resident was present. The second resident had a traumatic brain injury, seizures, hemiplegia of the left dominant side, moderately impaired cognition (BIMS score of 12), and was care planned as being at risk of being abused or mistreated by others and having the potential to abuse or mistreat others, with interventions including monitoring mood and providing early intervention on changes observed. Both residents used wheelchairs for locomotion. On the day of the incident, CNA #3 was monitoring the dining/dayroom shortly before 5:45 PM when the resident with traumatic brain injury appeared annoyed or upset upon the entry of the resident with Alzheimer’s disease. In response, CNA #3 escorted the resident with Alzheimer’s disease back to their room and then immediately returned to the dining room. CNA #3 did not notify the nurse or another CNA that the resident with traumatic brain injury was upset with the other resident, nor did they arrange for monitoring of the resident who had been redirected to their room to ensure they did not return to the dining room. Shortly afterward, the resident with Alzheimer’s disease wheeled themself back to the dining/dayroom and approached the table of the resident with traumatic brain injury. At that point, the resident with traumatic brain injury became angrier, picked up an empty meal tray, and struck the other resident on the head. CNA #3 was present in the dining room but was on the other side of the room assisting another resident and was unable to intervene in time to prevent the altercation. The resident who was struck was assessed and had no visible injuries, and the physician was notified. The other resident was sent to the hospital for evaluation and returned the next day with no recommendations. Facility leadership stated that the incident could have been prevented if the resident who had been redirected had been closely supervised or if staff had been informed of the potential for an altercation between the two residents.
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