Failure to Provide Required One-to-One Supervision Results in Resident Harm
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, high fall risk, and a physician's order for one-to-one supervision was not provided with the required supervision during an overnight shift. The resident had a history of restlessness, agitation, and attempts to get out of bed, as documented in behavioral monitoring notes and psychiatric assessments. The care plan and physician's order specifically required one-to-one supervision due to these behaviors and the resident's high risk for falls. On the night in question, the facility was understaffed, and no staff member was assigned to provide one-to-one supervision for the resident, despite this being documented as necessary in the care plan and physician's order. The assignment sheet for the shift did not indicate a one-to-one staff assignment, and interviews with staff confirmed that the required supervision was not provided. During the shift, the resident was observed awake and attempting to get out of bed, was transferred to a wheelchair, and remained at the nurse's station under general supervision, but not one-to-one monitoring. The resident later reported severe leg pain, which was not immediately assessed by the LPN on duty. The resident was eventually assessed by a registered nurse after a delay and found to have a swollen, painful right leg. The resident was transferred to the hospital, where an acute traumatic comminuted right femoral intertrochanteric fracture was diagnosed. Interviews with facility staff, including the DON and administrator, confirmed that the lack of one-to-one supervision was due to staffing shortages and that the required supervision was not provided during the shift in question. The incident resulted in actual harm to the resident.