Failure to Provide Required Supervision for Residents with Severe Cognitive Impairment
Penalty
Summary
The facility failed to provide supervision in accordance with the care plan for a resident with severe cognitive impairment, resulting in two incidents involving another resident with similar cognitive deficits. Both residents had diagnoses including dementia, major depressive disorder, anxiety, and cognitive communication deficits, and were assessed as having severely impaired cognition based on their BIMS scores. The care plans for both residents specifically directed staff to supervise them when together, with interventions including every 15-minute checks and, at times, 1:1 observation. On one occasion, a staff member observed the two residents together in a room, left to provide care for another resident, and returned approximately 15-20 minutes later to find both residents in bed without clothing. Although the care plan required supervision when the residents were together, staff did not provide the required level of supervision, and the residents were left alone for an extended period. Assessments following the incident found no injuries, and both residents denied discomfort or harm. Staff interviews confirmed awareness of the supervision requirements but revealed a lack of adherence to the care plan directives. Documentation and interviews indicated that staff failed to implement the care plan interventions as written, specifically the need for constant or frequent supervision when the two residents were together. The facility's policy required all clinical department heads to ensure implementation of resident care plans, but the supervision outlined in the care plans was not provided, leading to the incident where the residents were found unsupervised and unclothed in a private room.