Failure to Provide Ordered 1:1 Monitoring After Multiple Falls
Penalty
Summary
The deficiency involves the facility’s failure to implement a comprehensive, person-centered care plan and to follow a physician’s order for continuous one-on-one monitoring for a resident with multiple falls. The resident was admitted under hospice services with diagnoses including chronic obstructive pulmonary disease and major depressive disorder, had intact cognition per a BIMS score of 14, and was dependent on staff for transfers. The physician ordered one-on-one monitoring at all times for safety, including placement in a wheelchair or Geri-chair near the nurses’ station for monitoring each shift. The comprehensive care plan documented multiple falls and that the resident removed oxygen tubing, and one-on-one monitoring at all times for safety was added after a fall at 3:08 a.m. However, the incident log and progress notes showed the resident also had an unwitnessed fall at 1:30 a.m., indicating the ordered one-on-one monitoring was not consistently provided. Staff interviews further confirmed that the one-on-one monitoring order was not followed as required. Nursing staff reported the resident would remove oxygen tubing, become confused, not use the call light, and attempt to ambulate without assistance. The ADON and DON both stated that one-on-one monitoring required a staff member to observe the resident at all times, yet acknowledged that the resident had an unwitnessed fall when a CNA left the resident unsupervised to gather supplies and that staff assigned to one-on-one monitoring would leave the room to answer other residents’ call lights. The administrator confirmed there was no facility policy for one-on-one monitoring and that the physician’s order for continuous one-on-one monitoring was not followed when the unwitnessed fall occurred. The physician confirmed that one-on-one monitoring at all times had been ordered to increase supervision after multiple falls.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.