Failure to Document Post-Fall Vital Signs and Neurological Assessments
Penalty
Summary
The facility failed to ensure that vital signs and neurological assessments were documented for a resident following unwitnessed falls. The resident, who had diagnoses including hypertension, chronic kidney disease, type 2 diabetes mellitus, and urinary retention, experienced unwitnessed falls on two separate occasions. In both instances, the clinical records and incident reports did not include documentation of the required 72-hour follow-up vital signs or neurological assessments. Interviews with the DON confirmed that neurological assessments were not initiated after one of the falls, and documentation was not started for the other. A nurse involved was new and did not initiate the required records. Facility policies required that nursing staff monitor and document the resident's response and effectiveness of interventions for 72 hours following a fall, including completing and documenting neurological assessments and vital signs. Staff interviews confirmed that the expected practice was to assess for injuries and complete vital signs and neurological checks every shift for 72 hours, with documentation in the electronic health record. However, these procedures were not followed or documented as required for the resident after the unwitnessed falls.