Untrained Staff Assigned to 1:1 Supervision of Resident with Wandering Behavior
Penalty
Summary
The facility failed to ensure that staff members assigned to provide one-on-one (1:1) supervision for a resident with wandering behavior were properly trained and competent to meet the resident's behavioral health needs. Housekeeping staff were utilized as sitters for a resident with severe cognitive impairment and a history of wandering, despite not having received training on how to manage residents with such behaviors. Interviews with both a CNA and the Director of Staff Development confirmed that housekeepers were assigned to provide 1:1 supervision for the resident throughout April, and that these staff members had not been trained for this responsibility prior to their assignment. The resident in question had diagnoses including unspecified psychosis, altered mental status, impulse disorder, and unspecified dementia, with a severely impaired cognition score on the most recent assessment. Physician orders and the care plan specified the need for 1:1 supervision due to wandering risk. Despite this, the facility did not have a policy for managing residents requiring a sitter, and the Director of Nursing acknowledged that housekeeping staff should have received proper training before being assigned as sitters. Documentation and staff interviews confirmed that the housekeepers did not receive relevant training until after they had already been assigned to supervise the resident.