Failure to Perform Timely Neurological Assessments After Altercation
Penalty
Summary
The facility failed to perform neurological assessments according to its own policy for two residents following a physical altercation that had the potential for head trauma. Both residents were involved in a fist fight, with one sustaining minor cuts and a bruised cheek, while the other had no visible physical marks. The facility's policy required neurological checks every 15 minutes for the first hour after such incidents, but the medical records showed that neuro checks were only performed every hour for 72 hours post-incident, omitting the more frequent assessments required immediately after the event. Resident records indicated that one resident had diagnoses including schizophrenia and seizures, with intact cognitive skills and independence in daily living, while the other had schizophrenia and insomnia, also with intact cognitive skills and independence. The Director of Nursing confirmed that the neurological checks were not completed per policy, as the initial 15-minute interval checks were missed for both residents. The facility's policy, last revised in 2014, clearly outlined the required frequency of neurological assessments following potential head injuries, which was not followed in these cases.