Failure to Provide Adequate Supervision and Monitoring Resulting in Resident Harm
Penalty
Summary
A deficiency occurred when a resident with dementia, severely impaired cognition, and a history of aggressive behaviors was not provided with adequate supervision or a clearly defined monitoring plan, despite being care planned for frequent monitoring and placement on a secured unit. The resident's care plan included interventions such as assistance with all transfers, reminders, and one-on-one supervision as needed, but did not specify what constituted 'frequent monitoring.' There was no facility policy for supervision or monitoring, and staff reported that the level of supervision varied depending on the situation. Prior to the incident, the resident was not on any increased supervision, even though the care plan called for frequent monitoring. The resident had a documented history of verbal and physical altercations with other residents, including multiple incidents of arguments and agitation in the days leading up to the event. Progress notes indicated ongoing behavioral issues, but there was a lack of documentation regarding monitoring or behavioral interventions from the morning of two days prior to the incident until the time the resident was found injured. On the morning of the incident, the resident was found on the floor with severe facial bruising and swelling, reported pain, and stated she had been hit. The incident was unwitnessed, and staff were unable to provide a timeline for when the resident was last seen prior to being found on the floor. Subsequent investigation revealed that the resident sustained significant injuries, including a subdural hematoma, subarachnoid bleed, and intraparenchymal hematoma, and was admitted to the ICU. Staff interviews indicated that no one witnessed the incident, and there was confusion about the events leading up to the injury. The facility's self-reported incident and investigation documentation were incomplete, with missing details about the last time the resident was seen and the circumstances of the incident. The lack of a defined monitoring protocol and insufficient supervision contributed to the resident sustaining actual harm.