Incomplete Neurological Assessments After Resident Altercation
Penalty
Summary
The facility failed to ensure that a resident received complete neurological assessments for the required 72-hour monitoring period following a resident-to-resident altercation that resulted in a hit to the face. The resident, who had diagnoses including schizophrenia and depression and was assessed as having intact cognition and decision-making capacity, reported that staff had not performed neurochecks after the incident. Review of the resident's neurocheck flowsheet revealed missing documentation for one shift during the monitoring period, and staff interviews confirmed that the assigned licensed nurse did not complete the required assessments and documentation. Facility policy required neurological assessments and documentation following any head injury or when indicated by a change in condition. The Director of Nursing and a Licensed Vocational Nurse both acknowledged the importance of these assessments and that the facility's process was not followed in this case. The incomplete neurochecks and lack of documentation after the altercation constituted a failure to provide necessary care and services as outlined in the facility's policies.