Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement a comprehensive, person-centered care plan that addressed the need for 1:1 supervision for two out of four sampled residents. One resident, with diagnoses including depression, dementia, psychotic disturbance, mood disturbance, and anxiety, expressed suicidal ideation and was placed on 1:1 supervision per a nurse practitioner's order. However, there was no evidence in the electronic medical record (EMR) of continued 1:1 supervision from the evening until the resident was transferred to a behavioral hospital the following morning. Another resident, with a history of bipolar disorder, vascular dementia with psychotic disturbance and agitation, major depressive disorder, and anxiety, became aggressive and struck another resident. Following this incident, a nurse practitioner ordered 1:1 supervision and a psychiatric consult. Despite this order, there was no documentation in the EMR that 1:1 supervision was implemented for this resident from the time of the incident until the resident was transferred to a behavioral hospital. Facility leadership confirmed the lack of documentation and implementation of the ordered 1:1 supervision for both residents.