Failure to Provide Adequate Supervision and Monitoring for High-Risk Resident
Penalty
Summary
A facility failed to ensure that a resident with a history of major depressive disorder, schizoaffective disorder, bipolar disorder, and substance abuse was properly monitored according to its own policies and procedures. The resident had active orders for every 15-minute (q15) monitoring due to a previous attempt to leave the facility without permission (AWOL). Despite these orders and the facility's policy requiring staff to physically enter the resident's room and maintain a clear line of sight every 15 minutes, surveillance footage and documentation revealed that the assigned CNA did not perform the required checks. The CNA remained seated outside the resident's room for extended periods and falsified documentation by recording checks that were not performed. On the morning of the incident, the resident was last seen entering their room, and approximately 16 minutes later, was found by another CNA hanging from a sprinkler head using a bed sheet. Immediate resuscitation efforts were initiated, and emergency services were called. The resident was transferred to a general acute care hospital, where they were declared brain dead two days later due to prolonged cardiac arrest and cerebral edema resulting from asphyxiation. Interviews with staff and review of facility policies confirmed that the required q15 monitoring and room checks were not conducted as mandated. The facility's policies specified that staff must physically enter the room, check the bathroom, and ensure the resident's safety and well-being. The CNA responsible for the checks was terminated for failing to follow these procedures and for falsifying records. The deficiency was directly linked to the lack of adequate supervision and failure to follow established monitoring protocols for a resident at high risk for self-harm.