Resident Left Unattended After Fall Due to Missed Staff Rounds
Penalty
Summary
Staff failed to conduct required rounds on a resident who was dependent on staff for mobility and unable to use the call light or call out for help due to advanced Parkinson's disease and nonverbal status. Video evidence showed that the resident fell out of bed and remained on the floor for over three hours without staff checking on her. The last staff entry into the resident's room occurred late in the evening, and no one re-entered until early the next morning, at which point the resident was found on the floor. The resident's medical history included Parkinson's disease with dyskinesia, repeated falls, muscle weakness, disorientation, and dependence on a wheelchair. The resident required assistance with personal care and was unable to ambulate independently. The administrator confirmed that staff are expected to conduct rounds every two hours, especially for residents unable to seek help on their own, but this standard was not met in this case.