Failure to Complete and Document Neurological Checks After Resident Falls
Penalty
Summary
The facility failed to ensure that neurological evaluations were comprehensively conducted according to facility policy and procedure after falls for a resident with a history of falls and significant medical conditions, including Alzheimer's disease, muscle weakness, and a cervical fracture. The facility's policy required neurological checks at specific intervals and the inclusion of vital signs with each check following a known or suspected head injury. However, documentation revealed that after two separate falls, neurological checks were not performed or documented at the required intervals, and vital signs were not consistently obtained with each check as required by policy. For one fall, there was a significant delay between the initial and subsequent neurological checks, with vital signs not updated for several hours. In another incident, there was no evidence that neurological checks were performed every 15 minutes as required after the resident was found on the floor with a head injury, and vital signs from previous assessments were reused for multiple checks. Staff interviews confirmed that neurological checks and vital signs were not always completed or documented at the correct times, and that staff sometimes entered data later or failed to update the timing of vital signs. The Director of Nursing and the Administrator both acknowledged that the neurological checks were not completed correctly and that the use of previous vital signs for current assessments was inappropriate. The facility's own staff, including LPNs and a Doctor of Nursing Practice, confirmed that the expected protocol was not followed, and that neurological checks and vital signs should be performed and documented at the required intervals after a fall involving a potential head injury.