F0689

G

Failure to Implement Ordered 1:1 Safety Supervision Resulting in Self-Inflicted Injury

Syracuse, New York Survey Completed on 01-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure adequate supervision and implementation of a physician-ordered 1:1 safety watch for a resident with behavioral issues and prior smoking violations. The resident had diagnoses including opioid dependence, anxiety disorder, depression, and diabetes, and a psychological evaluation documented moderate depression symptoms, though at that time the resident was assessed as not being a danger to self or others. Following multiple smoking violations, the Interdisciplinary Team met on 12/28/2024 and agreed the resident was to be placed on 1:1 supervision for safety, and a telephone order for a 1:1 safety watch was obtained from a nurse practitioner. A subsequent physician order dated 12/30/2024 documented 1:1 for safety with an ongoing end date, and the comprehensive care plan, reviewed on 01/15/2025, included 1:1 supervision for safety as an intervention for behaviors and multiple smoking violations.

Despite the active 1:1 order and care plan intervention, documentation showed that the 1:1 safety watch was not consistently reflected on CNA assignment sheets prior to the resident’s hospitalization, and there was confusion among staff about the required distance and expectations for 1:1 supervision. Multiple CNAs reported having previously performed 1:1 safety watches for this resident due to smoking, generally staying within reach or at least within eyesight, often sitting outside the bathroom door or at the nurse’s station. Staff interviews revealed variability and lack of clarity in how “required distance” was interpreted, with some CNAs stating there was no clear definition and that the level of proximity depended on the resident and situation. The facility’s 1:1 Supervision policy required staff to stay within the required distance at all times, remain with the resident unless relieved, and complete necessary documentation, but practice as described by CNAs did not consistently align with these expectations.

When the resident was readmitted from the hospital on 01/15/2025, the facility failed to implement the existing 1:1 safety supervision order. The admission nurse was responsible for assessing the resident, entering orders into the computer, and contacting the medical provider to review orders, and the DON later stated that 1:1 safety watches required a physician order and would appear on the care plan and Kardex so staff would know via the care card. However, upon readmission, the resident was not placed on a 1:1 safety watch, there was no documented physician order discontinuing the prior 1:1, and the DON acknowledged uncertainty about why 1:1 was still listed on the care plan. The resident was cared for on a different floor after readmission, and a CNA who cared for the resident at that time confirmed the resident was not on a 1:1 safety watch. On 01/17/2025, two days after readmission without 1:1 supervision in place, the resident was found with a self-inflicted laceration to the neck and superficial vertical cuts to both wrists, resulting in actual harm that was not Immediate Jeopardy.