Failure to Provide Required 1:1 Supervision Resulting in Resident Harm
Penalty
Summary
A deficiency occurred when a resident who required continuous 1:1 supervision due to severe cognitive impairment, restlessness, agitation, and dependence on staff for transfers and toileting, was left unsupervised. The resident had a history of falls and had recently undergone a left hip replacement following a previous fall. Physician notes and care plans consistently indicated the need for 1:1 supervision and fall precautions due to the resident's high risk for accidents. Despite these documented needs, on the night in question, the nurse aide assigned to provide 1:1 supervision left the resident unattended to provide care to another resident without notifying anyone or obtaining coverage. The aide reported that the resident was restless throughout the night and did not have non-skid footwear on, as the resident had removed them. During the period the resident was left alone, the resident attempted to get out of bed and suffered an unwitnessed fall, resulting in lacerations, abrasions, and a traumatic brain injury, including a subarachnoid hemorrhage and cerebral contusion, as confirmed by hospital imaging. Interviews and facility documentation revealed that staffing issues contributed to the failure to maintain continuous supervision, with aides being rotated and dividing their time between 1:1 supervision and care for other residents. The nursing home administrator confirmed that the resident, who was identified as needing 1:1 observation, was not provided with the required close staff supervision at all times. This lapse in supervision directly led to the resident's fall and subsequent serious injuries.