Failure to Provide Ordered 1:1 Observation for Resident with Dementia
Penalty
Summary
A resident with diagnoses of dementia, anxiety, and psychosis was admitted to the facility and exhibited severe cognitive impairment, as indicated by a BIMS score of 3. The resident displayed behavioral symptoms that interfered with activities, intruded on the privacy of others, and disrupted the living environment, including hypersexual behaviors and significant wandering. Due to these behaviors, a physician's order was in place for 1:1 observation every shift, and the care plan included this intervention to address the resident's needs. Despite the physician's order and care plan, the facility failed to provide 1:1 observation for the resident during the night shifts from 6:00 p.m. to 6:00 a.m. on multiple occasions. Staff interviews confirmed that the required 1:1 observation was not consistently implemented during these hours. This lapse in following the ordered intervention resulted in the resident not receiving the appropriate treatment and services necessary to attain or maintain their highest practicable physical, mental, and psychosocial well-being.