Failure to Provide Required One-to-One Supervision Due to Inadequate Staffing Assessment
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. The assessment did not adequately consider specific staffing needs for each resident, nor did it adjust staffing based on changes in the resident population. This deficiency was evident during a review of staffing records, which showed that on a particular night shift, a resident with a physician's order for one-to-one supervision was not assigned a dedicated staff member as required. The resident in question had severe cognitive impairment, non-Alzheimer's dementia, anxiety disorder, and respiratory failure, and was dependent on staff for transfers and bed mobility. Despite an order for one-to-one supervision due to high fall risk and behavioral issues, staffing records and interviews confirmed that no staff member was assigned to provide this supervision during the night shift in question. Only two certified nursing assistants were present on the unit, and the resident was instead monitored hourly by available staff. The absence of one-to-one supervision resulted in the resident sustaining a right femoral fracture, which was later diagnosed at the hospital. Interviews with staff and facility leadership confirmed that the lack of one-to-one supervision was due to understaffing and unfilled shifts. The facility's assignment sheets and staffing plans did not reflect real-time adjustments for residents requiring enhanced supervision. Additionally, there was no dedicated documentation for one-to-one supervision assignments, and the physician who ordered the supervision was not notified when it could not be provided. This lapse led to actual harm to the resident.