Failure to Maintain 1:1 Supervision for Resident on Sitter Watch
Penalty
Summary
The facility failed to ensure that a resident requiring 1:1 monitoring was appropriately supervised in two separate instances. In the first instance, a Certified Nursing Assistant (CNA) assigned as a sitter was observed with her eyes closed for several minutes while on duty, and was not paying full attention to the resident as required. The Director of Nursing (DON) confirmed that the sitter was expected to remain within arm's length of the resident at all times and to continuously monitor the resident to prevent harm. The facility's policy also required staff to make routine checks to maintain resident safety and well-being. The CNA admitted to resting her eyes but denied being asleep, and a guard who witnessed the event reported it to management. In the second instance, another CNA assigned to 1:1 monitoring left the resident unattended in her room while he went to get supplies. The CNA acknowledged that he should not have left the resident alone and should have asked for assistance from other staff members. At the time of both incidents, the resident had diagnoses of dementia and anxiety disorder and had been placed on 1:1 monitoring following an altercation with another resident. Observations confirmed that the resident was left without staff supervision, contrary to facility policy and the expectations outlined by the DON.