Failure to Implement Ordered 1:1 Monitoring After Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and implementation of ordered monitoring after a resident-on-resident altercation. One resident with schizophrenia and major depressive disorder reported that another resident came from behind, stated there was a spider on the resident’s arm, and pinched the upper arm hard. Progress notes documented that the resident who was pinched became nervous around the aggressor following the incident. Both residents were assessed as having intact cognition and were largely independent in activities of daily living, with supervision needed only for personal hygiene. Following the altercation, the charge nurse notified the physician and obtained an order for the aggressor to receive 1:1 monitoring for two hours, followed by every 15-minute monitoring for two hours, due to physically assaultive behavior toward a peer. The physician’s order specified that this monitoring was to be documented in the electronic health record (Point Click Care) or on a 1:1 monitoring form. However, the charge nurse did not enter the 1:1 order into the electronic health record and did not assign a 1:1 sitter to the resident as required. Interviews and record review confirmed that the ordered 1:1 monitoring and subsequent Q15-minute checks were not initiated or documented in Point Click Care, contrary to the facility’s policy for timely and accurate 1:1 and Q15-minute monitoring documentation. The registered nurse supervisor and the DON both stated that facility policy required obtaining a 1:1 order for the aggressor after such an incident and initiating the monitoring in the electronic health record so that assigned CNAs could provide continuous direct line-of-sight observation and document every 15 minutes. Because the order was not entered, the aggressor was left unmonitored for more than two hours after the order was obtained.
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