Failure to Provide Ordered 1:1 Sitter Supervision Resulting in Unwitnessed Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow its own Safety and Supervision of Residents policy, as well as the physician’s order and care plan, to provide continuous 1:1 sitter supervision for a resident at high risk for falls. The resident was admitted with diagnoses including traumatic subdural hemorrhage, repeated falls, restlessness, and agitation. A Rehab Fall Risk Assessment dated 1/9/2026 documented that the resident required extensive assistance for bed mobility and transfers, used a wheelchair without proper safety, did not use the call bell properly, did not demonstrate safety techniques during transfers, and lacked sufficient strength and posture in sitting or standing. The H&P dated 1/10/2026 indicated the resident had the mental capacity to understand but could not make medical decisions. A physician’s order dated 1/13/2026 required 1:1 monitoring every shift because the resident constantly attempted to get out of bed unassisted. The MDS dated 1/14/2026 showed severe cognitive impairment and a need for maximal assistance for transfers and ambulation in the room. The resident’s care plan, also dated 1/14/2026, identified non-compliance with unassisted transfers and risk of falls/injuries, and directed CNAs to provide a 1:1 sitter. Despite this, the nursing assignment sheet for the 11:00 p.m.–7:00 a.m. shift on 1/15/2026 did not list a 1:1 sitter for the resident’s room, and progress notes from 1/15/2026 at 11:00 p.m. through 1/16/2026 at 7:00 a.m. contained no indication that 1:1 supervision was provided. On the 7:00 a.m.–3:00 p.m. shift on 1/16/2026, the nursing assignment indicated that a CNA was assigned as a 1:1 sitter for the resident’s room. However, a Change of Condition note dated 1/16/2026 documented that at 8:30 a.m. the resident got out of bed to go to the bathroom without using the call light, his knees buckled, and he made contact with the floor, sustaining a small bump and superficial cut to the nose with minimal bleeding. The COC did not indicate that a 1:1 sitter was present or that the fall was witnessed. Interviews with CNAs, the MDS Coordinator, and the DON confirmed that the resident had an order for continuous 1:1 monitoring, that no sitter was present at the end of the night shift, that the fall was unwitnessed, and that the physician’s orders and care plan for 1:1 supervision were not followed. The facility’s policy required targeted interventions, including adequate supervision, to be implemented correctly and consistently, which did not occur in this case.
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