Failure to Provide One-on-One Supervision for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to provide one-on-one supervision for a resident with severe mental impairment and a diagnosis of Alzheimer's disease, despite documented incidents of inappropriate sexual behavior with other residents. The resident had a Brief Interview for Mental Status (BIMS) score indicating severe impairment and was deemed incompetent to make medical decisions. Progress notes revealed that staff had been attempting to keep the resident separated from female residents, but the resident was found in bed with a female resident on multiple occasions, including incidents where inappropriate sexual contact occurred. Although a plan for one-on-one supervision was mentioned in progress notes, it was not formalized as a physician's order, and there was no consistent documentation or communication to ensure all staff were aware of the supervision requirement. Interviews with staff indicated a lack of clarity and documentation regarding the implementation of one-on-one supervision. Some staff members were unaware of the supervision requirement, and assignment sheets did not reflect that one-on-one supervision was in place for the resident. Additionally, behavior monitoring logs and daily assignment sheets lacked documentation of the resident's behaviors and supervision status. The absence of clear orders, documentation, and communication led to repeated incidents where the resident was unsupervised and engaged in inappropriate behavior with other residents.