Resident Left Unsupervised, Sustains Injury Due to Failure to Follow Supervision Requirements
Penalty
Summary
A deficiency occurred when a resident with severe intellectual disabilities, anxiety disorder, obsessive-compulsive disorder, and bilateral cataracts was not provided the required level of supervision as outlined in their care plan. The resident, who had a history of falls and was assessed as needing Level of Supervision (LOS) 3 due to lack of safety awareness, impaired vision, and poor coordination, was left unsupervised in a back hallway. The assigned staff member left the resident alone to take out the garbage without notifying other staff, despite the care plan requiring the resident to always be within staff's line of sight. As a result of being left unsupervised, the resident experienced an unwitnessed fall or contact with a firm surface, leading to a hematoma and bruising around the right eye. Staff later found the resident walking in the hallway with visible injuries. Interviews confirmed that the staff member did not follow the care plan and failed to communicate the resident's whereabouts to other staff, resulting in the resident being left alone and sustaining harm.