Failure to Provide Required 1:1 Supervision and Adequate Staffing
Penalty
Summary
The facility failed to provide sufficient and competent staff to implement a resident's care plan interventions. Clinical record review showed that a resident with dementia, insomnia, wandering, restlessness, and agitation was assessed as having memory impairment and was able to walk without assistance. The resident was identified as an elopement risk, and the care plan included 1:1 observation as an intervention. On September 17, 2025, a physician ordered 1:1 supervision for this resident. However, facility documentation revealed that the staff member assigned to provide 1:1 supervision left the assignment at 8:00 p.m. on September 20, 2025, and was not replaced, leaving the resident without required supervision. As a result, the resident eloped from the facility later that night. Additionally, staffing documentation indicated that the facility did not meet the state-required nurse aide ratios and minimum direct care hours per resident on that day.