Failure to Provide Required 1:1 Supervision for High-Risk Resident
Penalty
Summary
A deficiency occurred when a staff member assigned to provide 1:1 protective supervision for a resident with profound intellectual disabilities, severe cognitive impairment, self-injurious behavior, and pica was found asleep while on duty. The resident required total care with activities of daily living and had a care plan specifying the need for constant supervision in both the morning and evening. The facility's policy emphasized maintaining resident safety and well-being, and the care plan clearly outlined the need for vigilant monitoring due to the resident's high-risk behaviors. The incident was discovered when the resident was absent from the dining room during lunch, prompting a staff member to check on them. Upon entering the resident's room, the staff member found both the resident and the assigned CNA asleep, with the CNA failing to provide the required supervision. Interviews with facility staff, including the DON and a registered nurse, confirmed that staff assigned to 1:1 supervision are expected to remain alert and attentive at all times, and that sleeping while on duty constitutes a failure to follow the care plan and facility policy.