Failure to Provide Ordered One-to-One Supervision for Resident with History of Self-Harm
Penalty
Summary
A deficiency occurred when facility staff failed to provide ordered one-to-one supervision in direct line of sight for a resident with a known history of self-harm. The resident, who had multiple psychiatric diagnoses including schizophrenia, bipolar disorder, borderline personality disorder, and a documented history of self-injury and suicide attempts, was placed on one-to-one monitoring per physician order and care plan. The care plan specified that staff were to supervise the resident at all times, especially when the resident had access to sharp objects, and to never leave the resident alone with such items. Despite these orders and the facility's policy requiring one-to-one supervision within eyesight, the assigned CNA sat outside the resident's room with the door closed during the night shift. The CNA reported being told by an unknown staff member that it was acceptable to sit outside the room and keep the door closed, and was unaware of the requirement to remain inside the room with the resident. During this period, the resident accessed a pair of small scissors hidden in a birthday gift and used them to inflict a 7 cm by 3 cm laceration on their left forearm. The incident was not immediately detected by staff, as the resident did not communicate their distress or the act of self-harm to the staff member assigned to monitor them. The failure to maintain direct line-of-sight supervision allowed the resident to self-harm without intervention. The incident was discovered only after the resident sought help from an LPN for a PRN medication, at which point the injury was noticed. Interviews with staff and the resident confirmed that the required supervision protocols were not followed, and that the resident was left unsupervised with the door closed, contrary to facility policy and physician orders.