Failure to Provide Required 1:1 Supervision Resulting in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with intellectual disabilities, autistic disorder, and schizoaffective disorder, who was assessed as having severely impaired cognitive skills and a history of impulsive and self-injurious behaviors, was not provided with the required one-on-one (1:1) supervision as indicated in their care plan. The care plan, established by the interdisciplinary team, specified that the resident should receive 1:1 supervision for 10 hours daily due to their impaired cognition and behavioral risks. On the day of the incident, the assigned staff member left the resident unsupervised in their room for approximately 30 seconds, during which time the resident fell from their wheelchair. As a result of being left unsupervised, the resident sustained a laceration above the left eyebrow, abrasions to the left elbow and forearm, and a bruise under the left eye. The injuries required emergency medical attention, and the resident was transferred to a general acute care hospital for further evaluation and wound management. Staff interviews confirmed that the resident was known to require constant supervision due to their behavioral tendencies and risk of harm, and that the assigned staff was aware of the supervision requirement but failed to maintain it at the time of the fall. Facility records, including progress notes, care conference documentation, and staff interviews, consistently indicated that the resident's need for 1:1 supervision was well established and communicated among the care team. The facility's policy on safety and supervision emphasized the importance of implementing and communicating specific interventions to prevent accidents, but in this instance, the intervention was not carried out as required, directly leading to the resident's fall and subsequent injuries.