Inaccurate Documentation of Neurological Checks
Summary
The facility failed to maintain accurate and complete medical records for a resident who experienced a head injury. The resident, who had a history of [MEDICAL CONDITION] and was at risk for falls, was found in bed with a small laceration on the back of the head after reportedly having a bad dream. Neurological checks were ordered by the attending physician and documented by staff. However, the documentation continued even after the resident was transferred to the hospital, indicating that the checks were inaccurately recorded for a period when the resident was no longer present in the facility. The facility's policy required neurological checks to be conducted for 24 hours following a head trauma unless otherwise directed by a physician. Despite this, the documentation showed that neurological checks were recorded at scheduled intervals, including times after the resident had been transferred to the hospital. This discrepancy was acknowledged by the Director of Nursing, who confirmed that staff should not have documented checks for a resident who was not in the facility. The inaccurate documentation of neurological checks led to the deficiency cited in the report.
Plan Of Correction
Plan of Correction: Approved January 14, 2025 The facility acknowledges resident #1 was affected by this deficient practice. Resident #1’s Neurological checks sheet was reviewed, to ensure it reflected the appropriate time frame and updated accordingly. A full house audit was conducted on all residents on neurological checks to ensure they are filled out accurately by the director of nursing or designee. All current residents on neurological checks were reviewed to ensure compliance with no issues identified. A lesson plan was developed for education, and all LPNs and RNs will be educated on accurate documentation in the medical record and specifically the neurological checks. The facility policy on Neurological checks was reviewed on 1/6/25 with no changes made. The director of nursing/designee created an audit to ensure all neurological checks are completed accurately. The director of nursing/designee will conduct a weekly audit on 10% of all residents on neurological checks to ensure they are completed accurately to ensure compliance for 8 weeks, then monthly thereafter until 100% compliance is achieved. Any negative audit findings will be immediately addressed by the DNS/designee with an onsite teaching/inservice and disciplinary action as needed. The findings of these audits will be discussed by the DNS/designee at the QA meetings monthly for 3 months, then quarterly in order to review and discuss any unfavorable patterns that may prevent achieving 100% compliance. The director of nursing is responsible for the correction and completion of this deficiency.
Penalty
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