Failure to Provide and Document Required 15-Minute Monitoring After Change from 1:1 Supervision
Penalty
Summary
The facility failed to provide necessary supervision and monitoring for a resident diagnosed with schizophrenia, as required by physician orders following a change from 1:1 monitoring to every 15-minute checks. Documentation revealed that there was no record of the resident being monitored from 1:30 p.m. to 11:45 p.m. on the specified date, despite the physician's directive and facility policy requiring such monitoring. Multiple staff members, including RNs, LVNs, and CNAs, confirmed during interviews that the monitoring was not documented and, in some cases, staff were not informed of the change in monitoring frequency. The facility's policy stated that staff should assess and observe the resident's behavior and document it every 15 minutes. However, both the monitoring and the required documentation were not completed for a significant period. Staff interviews indicated a lack of communication regarding the change in monitoring status, and the assigned staff did not recall performing or recording the required 15-minute checks. This resulted in a failure to provide the supervision and documentation mandated by the physician's order and facility policy.