Inadequate Supervision During Resident Ambulation Due to Staff Phone Use
Penalty
Summary
A deficiency occurred when an occupational therapist (OT) failed to provide adequate supervision to a resident with moderate cognitive impairment and limited vision. The resident, a male with a diagnosis of senile degeneration of the brain and ADL self-care performance deficits related to COPD and fatigue, was observed ambulating with a cane while the OT walked behind him, pushing his wheelchair. During this time, the OT was distracted by her phone, looking at pictures and not paying attention to the resident, contrary to facility policy and her training. Interviews with the OT, DON, and ADM confirmed that staff are not permitted to use personal phones during resident care, especially while providing mobility assistance, as outlined in the facility's policies. The OT acknowledged that her inattention could have resulted in serious injury if the resident had fallen. Facility records and interviews further confirmed that staff had received in-service training on the prohibition of phone use during resident care, and that the policy specifically prohibits therapy staff from using phones while ambulating patients.