Failure to Follow Consultant Recommendations and Neuro Check Protocols
Penalty
Summary
Facility staff failed to provide care in accordance with consultant recommendations for a resident admitted with anemia and thyrotoxicosis. The resident was evaluated by a consultant who recommended starting an appetite stimulant and a prosource protein supplement due to poor appetite and low albumin levels. Despite these recommendations, the staff did not initiate either intervention before the resident was discharged from the facility. The Director of Nursing confirmed that these recommendations were not addressed. Additionally, staff did not properly perform and document neurological assessments following an unwitnessed fall for another resident. According to facility policy, neuro checks should be completed at specific intervals after such an event. However, the medical record showed that neuro checks were not performed or documented at the required times, and some entries included inaccurate or reused vital signs. The Director of Nursing confirmed that neuro checks were completed at incorrect intervals and with inaccuracies.