Failure to Complete Timely Assessments After Injury and Elopement
Penalty
Summary
The facility failed to initiate and complete timely and thorough assessments for a resident with severe cognitive impairment and multiple medical conditions, including Alzheimer's disease, muscle weakness, and a history of fracture. On one occasion, staff observed facial bruising on the resident after she reported being knocked into a wall by another resident, but did not conduct a comprehensive head-to-toe assessment or initiate neurological checks at the time of discovery. Documentation of vital signs was inconsistent, and neurological checks were not started until the following day, with incomplete entries and no ongoing monitoring as required. Additionally, after the resident eloped from the facility and returned, staff did not perform a thorough assessment to evaluate her condition post-elopement. Interviews with nursing staff revealed a lack of understanding regarding the need for assessments after such incidents, and the Director of Nursing confirmed that assessments should be completed after falls, altercations, or elopements, but acknowledged the absence of a facility policy guiding these practices. The facility also lacked documentation of a policy for head-to-toe assessments or neurological checks.