Missing Documentation of Post-Fall Neurological Assessments
Penalty
Summary
The facility failed to ensure that medical records were updated with post-fall neurological evaluations for a resident who experienced an unwitnessed fall. Record review showed that the resident was found between beds with a curtain over her head and her leg over a bedside table leg. Although nursing staff are required to begin neurological checks immediately after being notified of an unwitnessed fall and to document these evaluations using a specific form, the resident's electronic health record did not contain the required post-fall neurological assessments. Interviews with staff confirmed that the neurological evaluations were not present in the medical records at the time of review, and the Director of Nursing later acknowledged that the documentation should have been included in the resident's electronic health record but was not.