Failure to Perform Required Resident Rounds Resulting in Entrapment and Death
Penalty
Summary
Facility staff failed to monitor a resident at least every two hours as required by facility policy and based on the resident's needs. The resident, who was moderately cognitively intact and required two staff for bed mobility and transfers, was not checked between 11:00 P.M. and 3:10 A.M. Staff interviews and record reviews confirmed that the assigned CNA did not observe the resident during this period, and the LPN responsible for the resident's IV medication also did not return to the room to disconnect the IV as required. The resident had a physician's order for enablers (grab bars) on both sides of the bed and required significant assistance for mobility and transfers. The resident's baseline care plan indicated the need for a mechanical lift and two staff for bed mobility, transfers, and toileting. Despite these needs, staff did not assess or document the use of bed rails or grab bars, and the resident was left unattended for over four hours during the night shift. At approximately 3:10 A.M., the resident was found entrapped between the bedrail and mattress, face down and unresponsive. Staff had to forcefully remove the resident's head from between the rail and mattress. CPR was initiated, and emergency services were called, but the resident was pronounced dead. The investigation confirmed that the required two-hour checks were not performed, and both the CNA and LPN failed to monitor the resident as per policy and the resident's care plan.