Failure to Provide Required One-to-One Supervision for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide proper supervision for a resident with severe cognitive impairment, resulting in two separate altercations with other residents. The resident in question had a BIMS score of 3, indicating severe cognitive impairment, and diagnoses including hypertensive heart disease, anemia, renal failure, psychotic disorder, mild cognitive impairment, insomnia, and metabolic encephalopathy. The care plan for this resident included interventions for delusions and impaired short-term memory, with specific instructions for staff to reorient and redirect the resident as needed. Following an initial altercation with another resident, the care plan was updated to require one-to-one supervision while the resident was awake due to increased delusions. Despite the updated care plan, staff failed to maintain the required one-to-one supervision. On the day following the first incident, the resident was involved in a second altercation, this time with a different resident in the dining room. Staff interviews and documentation revealed that, although the resident was supposed to be under constant supervision, there was confusion among staff regarding who was responsible for the supervision at the time of the second incident. Staff members were occupied with other duties, such as assisting another resident who had fallen, and were not physically present with the resident as required by the care plan. The lack of clear assignment and documentation for one-to-one supervision contributed to the failure to prevent the second altercation. Further review of facility practices showed that there was no accessible documentation or clear protocol available to staff regarding the implementation of one-to-one supervision. The MDS Coordinator was unable to provide documentation for the supervision during the relevant period, and staff interviews indicated uncertainty about the expectations and procedures for one-to-one supervision. The administrator confirmed that staff were not within the required proximity to the resident during the incident, and there was no indication that alternative supervision measures, such as 15-minute checks, were implemented when one-to-one supervision could not be maintained.