Failure to Provide Required 1:1 Supervision Results in Resident Harm
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of a resident who required 1:1 supervision as ordered by the physician. The resident, who had diagnoses including restlessness, agitation, lack of coordination, and difficulty walking, was assessed as severely cognitively impaired and dependent on staff for transfers and toileting. Despite documented orders and care plans for continuous 1:1 supervision due to safety concerns and increased behaviors, staffing records showed the facility was short-staffed during the relevant night shift, providing fewer nurse aide and LPN hours than required for the census and resident needs. On the night in question, the nurse aide assigned to provide 1:1 supervision for the resident left the room to attend to another resident's personal hygiene needs without notifying anyone, leaving the resident unsupervised. During this period, the resident, who was restless and had removed non-skid footwear, fell from the bed. The incident was discovered when the nurse aide heard a noise and found the resident on the floor with lacerations and abrasions. The resident was unable to recall the incident or report pain, and a neurological assessment was performed. Following the fall, the resident was transferred to the hospital, where diagnostic imaging confirmed traumatic brain injury, including subdural hematomas and subarachnoid hemorrhage. Facility documentation and staff interviews confirmed that the required 1:1 supervision was not maintained due to inadequate staffing, directly resulting in the resident being left unsupervised and sustaining actual harm.