Failure to Provide Required 1:1 Supervision for High-Risk Resident
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including encephalopathy, hemiplegia, hemiparesis following cerebral infarction, and dysphagia, was left unsupervised in his room despite being care planned for one-to-one supervision due to high risk for falls and elopement. The resident had severely impaired cognition and a documented history of falls, with a Morse Fall Assessment score indicating high risk. During observation, the resident was found sitting on the edge of his bed with his call light on the floor and no staff or sitter present, despite requiring assistance with meals and supervision at all times. Staff interviews confirmed that the resident should have had continuous one-to-one supervision, and the assigned sitter was observed exiting the resident's bathroom, leaving the resident unattended. The care plan and staff training records indicated that the expectation was for the resident to never be left unattended, and the DON confirmed that staff are expected to arrange relief if a sitter needs a break. The facility was unable to provide a specific policy for sitter or supervision when requested.