F0725

E

Failure to Provide and Assign Required 1:1 and Enhanced Monitoring

Lakeland, Florida Survey Completed on 03-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide and document required 1:1 supervision, enhanced monitoring (EM), or continuous monitoring (CM) for multiple residents who had behavioral symptoms, suicidal ideation, or elopement risk. For one resident with dementia and behavioral disturbance who had pushed another resident, nursing notes documented placement on 1:1 monitoring after the altercation, but CNA assignment sheets for several subsequent shifts showed no resident listed or staff assigned for 1:1. On another date, a CNA was listed as assigned to 1:1 supervision without any resident name or room number, and on other shifts there was no 1:1 assignment at all, despite progress notes indicating the resident was on 1:1 or enhanced monitoring.

A second resident with dementia, psychosis, and depression had an order for continuous observation for elopement. Progress notes described wandering, agitation, and increased supervision due to elopement risk. However, CNA assignment sheets for multiple shifts showed no resident documented or staff assigned for 1:1 supervision, and on one shift a CNA was assigned 1:1 supervision for two residents in the same room. A third resident with Alzheimer’s disease and documented suicidal ideation had physician orders for 1:1 supervision and continuous observation for suicide ideation. Progress notes repeatedly stated the resident remained on 1:1 or continuous observation, yet CNA assignment sheets showed staff assigned to 1:1 while also responsible for a full group of rooms, and on later dates there were no residents documented or staff assigned for 1:1 on any shift, even while notes continued to reference continuous observation.

Another resident with depression and active suicidal thoughts had multiple physician orders for 1:1 observation and continuous observation for suicidal ideation following a behavioral incident. Progress notes documented a 24‑hour sitter, ongoing 1:1, and continued close observation, but CNA assignment sheets for several dates and shifts showed no staff assigned for 1:1, including entire days with no 1:1 assignment despite notes indicating the resident continued on 1:1. A further resident with vascular dementia, agitation, and a history of wandering and resident‑to‑resident altercations was described in progress notes and psychiatric documentation as being on 1:1 supervision or enhanced monitoring after aggressive incidents, yet CNA assignment sheets and staffing records showed multiple shifts with no 1:1 assignment, shifts where EM was assigned to one CNA for two residents in different rooms, and night shifts with no EM or 1:1 documented for this resident.

A final resident with dementia and sexually inappropriate behavior had a care plan intervention for enhanced monitoring after a sexual incident with a peer. Progress notes did not document 1:1, EM, or CM, and CNA assignment sheets showed shifts with no staff assigned for 1:1 or EM, as well as shifts where one staff member was assigned EM for this resident and another resident in different rooms. Interviews with nursing and CNA staff revealed inconsistent understanding and implementation of 1:1 and EM: one LPN stated staff should not have both a regular assignment and a 1:1 due to safety concerns, while CNAs reported being instructed to provide 1:1 while also caring for other residents, sometimes rotating the 1:1 among staff and bringing the supervised resident along while performing other care. Leadership interviews showed conflicting definitions of 1:1, EM, and continuous monitoring, disagreement about whether physician orders were required, and reliance on verbal reporting and care plans rather than consistent written assignments and documentation, despite multiple residents being described as on 1:1 or EM at the time.