Failure to Provide Adequate Supervision and Behavioral Health Support
Penalty
Summary
The facility failed to ensure sufficient staff with the necessary competencies and skills to meet the behavioral health needs of a resident with a history of dementia, schizophrenia, and depression. The resident exhibited behaviors such as wandering, entering other residents' rooms, and urinating or defecating in inappropriate places. The individualized care plan required ongoing monitoring, redirection, and thirty-minute safety checks, but these interventions were not consistently implemented. Documentation revealed that thirty-minute checks were missing for entire shifts on most days within a one-month period, and staff interviews confirmed that these checks were not always completed or signed for as required. Multiple observations showed the resident wandering unsupervised in hallways and other residents' rooms, including entering a room under contact precautions and defecating in a public area. Staff were not consistently present to redirect or supervise the resident, and on several occasions, the resident was only redirected after being observed by staff who were exiting other rooms. Family members and other residents' visitors reported witnessing the resident engaging in inappropriate toileting behaviors and wandering without supervision, sometimes having to call for staff assistance themselves. Interviews with staff and management indicated that while there were expectations for regular monitoring and redirection, staffing levels and the availability of unit assistants were inconsistent. Staff acknowledged that the required thirty-minute checks were not always performed, and that unit assistants, who provided additional supervision and engagement, were not present every day. The lack of consistent supervision and incomplete documentation of required checks contributed to the facility's failure to maintain the resident's highest practicable physical, mental, and psychosocial well-being as outlined in the care plan.