Failure to Provide Required One-to-One Supervision and Timely Assessment
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, specifically failing to assign one-to-one supervision for a resident with severe cognitive impairment, a history of falls, and a physician's order for continuous supervision. On the night in question, the assignment sheet and staffing records showed that the resident was not assigned a one-to-one staff member during the overnight shift, despite the physician's order. Only two certified nursing assistants were present on the unit, and the scheduled one-to-one aide did not show up, with no replacement found due to ongoing staffing challenges. During the overnight shift, the resident was observed awake and attempting to get out of bed. Staff transferred the resident to a wheelchair and brought them to the nurse's station for monitoring, but there was no dedicated one-to-one supervision as required. The resident remained at the nurse's station until the next shift, when a home health aide arrived and was assigned to provide one-to-one supervision. At that time, the resident reported severe leg pain, which was not immediately assessed by the outgoing LPN, who instead instructed the aide to wait for the incoming nurse. The incoming nurse and registered nurse subsequently assessed the resident, noted swelling and pain, and arranged for hospital transfer, where an acute right hip fracture was diagnosed. Interviews with staff and leadership confirmed that the lack of one-to-one supervision was due to understaffing and that the physician was not notified that the ordered supervision could not be provided. The DON and administrator acknowledged that the resident did not receive the required supervision and that staff failed to respond promptly to the resident's report of pain. The incident resulted in actual harm to the resident, as documented by the hospital diagnosis and facility investigation.