Failure to Complete Neurological Assessments After Resident Fall
Penalty
Summary
The facility failed to complete neurological assessments as required following a resident's fall. A resident reported falling out of bed, hitting his head, and being sent to the hospital, after which he returned to the facility the same day. According to facility staff, neurological checks are to be performed for 72 hours after a fall involving a head injury or an unwitnessed fall, and these checks should continue upon the resident's return from the hospital. However, the neurological assessment documentation did not begin until late in the evening on the day of the fall, and two hourly checks were missed in the early afternoon after the resident's return. The documentation also lacked an initial incident time, indicating incomplete monitoring and record-keeping as per facility protocol.