Failure to Complete Neurological Assessments After Unwitnessed Falls
Penalty
Summary
The facility failed to perform neurological assessments as required following unwitnessed falls for a resident with severe cognitive impairment. Clinical record reviews and incident reports showed that the resident, who had diagnoses including Alzheimer's dementia, anxiety disorder, depression, and bipolar disorder, experienced 14 falls since May 2024. Of these, 7 were unwitnessed falls, and the facility did not complete neurological assessments as mandated by their policy. The policy specifies that neurological checks must be performed after any unwitnessed fall, regardless of whether the resident denies hitting their head, unless the resident is alert, oriented, and has a BIMS score of 12 or higher. The resident in question had a BIMS score of 00, indicating severe cognitive impairment, and therefore did not meet the exception criteria. Incident reports for each unwitnessed fall documented the circumstances, such as the resident being found on the floor in various locations, but did not include evidence of completed neurological assessments. Staff interviews confirmed that neurological assessments were not performed for these incidents, and the DON acknowledged the failure to follow the facility's policy. The lack of neurological assessments was not due to any documented clinical judgment or exception, but rather a misunderstanding or disregard of the policy requirements.