Failure to Implement and Document Enhanced/1:1 Supervision After Sexual Behavior Incident
Penalty
Summary
The deficiency involves the facility’s failure to implement and document a comprehensive care plan intervention for enhanced or one-to-one supervision for a resident with known behavioral and cognitive impairments. The resident was admitted with multiple dementia-related diagnoses, including Alzheimer’s disease, vascular dementia with behavioral disturbances, anxiety disorders, and major depressive disorder. The facility’s reportable incident log documented a sexual allegation involving this resident and another resident. Following this, the resident’s comprehensive care plan identified that he could be sexually inappropriate at times related to his dementia diagnosis, and an intervention of “enhanced monitoring by staff as necessary” was added. However, review of progress notes from the days surrounding the incident showed no documentation of 1:1 supervision, enhanced monitoring, or continuous monitoring being provided. Interviews with facility staff revealed inconsistent understanding and implementation of supervision interventions. The DON stated that enhanced supervision was different from 1:1 supervision and that enhanced supervision did not require a physician order and was communicated verbally between nurses, with documentation expected in progress notes. In contrast, an RN/UM reported that 1:1 supervision and enhanced monitoring were the same and that an order would be in place for nurses to document, with the intervention reflected on the care plan and Kardex. The ADON stated that a physician order was needed for 1:1 supervision and that the expectation for residents on 1:1 or enhanced monitoring was implementation of a care plan and documentation in progress notes. Despite these expectations and the facility’s policy requiring care plans to be updated and implemented based on resident assessments and condition changes, there was no evidence in the record that the enhanced or 1:1 supervision interventions were consistently implemented or documented for this resident after the incident.
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