Failure to Provide Required 1:1 Supervision for Resident with Wandering Behavior
Penalty
Summary
The facility failed to provide one-on-one (1:1) supervision for a resident with severe cognitive impairment and a history of wandering, as required by the physician's order and the resident's care plan. Multiple staff interviews and record reviews revealed that there were several occasions when no assigned sitter was present for the resident, and the responsibility to monitor the resident was informally distributed among all available staff. Assignment sheets and sitter schedules showed blank entries for numerous shifts, indicating the absence of a designated sitter during those times. The resident in question had diagnoses including unspecified psychosis, altered mental status, impulse disorder, and dementia, with a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating severely impaired cognition. The care plan specifically identified the resident as an elopement risk and required 1:1 supervision due to wandering behaviors. Despite this, staff reported that when no sitter was available, they were instructed to "keep an eye" on the resident while also attending to their other assigned duties, and sometimes non-clinical staff such as housekeepers were assigned as sitters. Documentation reviewed for the month showed multiple periods where no staff signatures were present to confirm 1:1 supervision, and staff confirmed that these blank periods meant the resident was not being directly supervised as required. The Director of Nursing acknowledged that the resident should not have been left without a sitter at any time while the order was in place, and the facility did not have a specific policy for managing residents who require a sitter.