Failure to Provide Ordered 1:1 Supervision and Continuous Observation for Two High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and care plan interventions for 1:1 supervision and continuous observation for two residents, resulting in both residents being left unattended at various times. Resident 1 was admitted with hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, and contractures of the right upper arm and right knee. Assessment documents showed Resident 1 required substantial/maximal assistance with most ADLs and had a high fall risk score of 19 on the facility’s fall risk evaluation, with a care plan identifying risk for falls related to confusion and a history of attempting to get out of bed unassisted. The care plan and physician orders required 1:1 supervision, maintenance of 1:1 observation at all times, and that Resident 1 not be left unattended. Resident 2 was admitted with dementia, Alzheimer’s disease, and an anxiety disorder, and had moderately impaired cognition. The MDS indicated Resident 2 required supervision or touching assistance for toileting, bathing, dressing, footwear, and personal hygiene. Physician orders and care plans dated 1/30/26 documented 1:1 supervision for Resident 2 due to episodes of aggression toward staff, exit-seeking behavior, unprovoked agitation, crying, and aggression, with interventions specifying that a 1:1 sitter be placed with the resident for safety, that the resident not be left unattended, that a reliever be requested before the sitter went on break, and that 1:1 observation be maintained at all times. Despite these orders and care plan directives, the facility’s sitter schedule for the night shift on 2/1/26 showed a single sitter (S1) assigned simultaneously to both residents. Observations and staff interviews confirmed that the 1:1 supervision orders were not implemented as written. During an early morning observation in Resident 1’s room, S1 was present with Resident 1, whose bed was positioned against a wall with a Geri chair wedged tightly against the bed frame on the other side, creating a physical barrier. S1 reported having permission from the DON to place the Geri chair next to the bed. LVN 1 stated that S1 was assigned as a 1:1 sitter for both residents and had to go back and forth between their rooms every 15–20 minutes, even though a 1:1 order meant one sitter should be dedicated to one resident for the entire shift. LVN 1, CNA 1, CNA 2, the RN supervisor, the DON, and the Administrator all acknowledged that each resident with a 1:1 order should have continuous supervision, should not be left alone, and that another staff member should cover when the sitter left the room. Direct observation showed S1 leaving Resident 1 alone to walk down the hallway and around a corner to briefly check on Resident 2, then leaving Resident 2 alone to return to Resident 1, while S1 also described Resident 2 as unpredictable, with a history of hitting other residents and staff and throwing objects. These observations and interviews demonstrated that both residents, each with a physician’s order and care plan for continuous 1:1 supervision and not to be left unattended, were in fact left alone at times, and that one sitter was inappropriately assigned to cover both residents.
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