Failure to Provide Adequate Supervision and Required Assistance Resulting in Resident Harm
Penalty
Summary
Facility staff failed to provide adequate supervision for a resident with a known history of inappropriate sexual behavior, resulting in actual harm to another resident. Despite multiple incidents and psychiatric evaluations documenting ongoing inappropriate behaviors, the care plan for the resident exhibiting these behaviors was not updated to include increased supervision. On one occasion, a staff member witnessed the resident inappropriately touching another severely cognitively impaired, nonverbal resident, who was found tearful and distressed. The care plan interventions focused on medication management and behavioral monitoring but did not address the need for enhanced supervision to protect other residents. Additionally, the facility did not ensure that two-person assistance was provided during bed mobility care for a resident as required by the care plan. Documentation revealed that, out of 52 bed mobility tasks, 30 were performed with only one staff member, contrary to the resident's designation for two-person physical assistance. This failure led to an incident where the resident rolled out of bed during care by a single staff member, resulting in a laceration above the right eyebrow. Both deficiencies were identified through record reviews, incident reports, and staff interviews. The lack of appropriate supervision and failure to follow care plan requirements directly contributed to harm and injury to the residents involved.