Failure to Provide Adequate 1:1 Supervision Due to Lack of Policy and Training
Penalty
Summary
The facility failed to provide adequate supervision to prevent incidents for a resident requiring 1:1 monitoring. During multiple observations, a staff member assigned to 1:1 monitoring was unable to maintain direct visual contact with the resident due to the resident's door being closed or only slightly open with the privacy curtain pulled. Interviews with facility staff revealed that there was no formal policy in place for 1:1 observation, and staff assigned to this duty had not received formal training on the procedures. A review of staff in-service training showed that education on 1:1 monitoring had been conducted, stating that the resident should be within eyesight and arm's reach at all times, but this was not consistently implemented. There was no facility policy to guide staff on 1:1 observation practices.