Failure to Perform Neurological Assessments After Unwitnessed Fall
Penalty
Summary
The facility failed to provide ongoing neurological assessments following an unwitnessed fall for one resident. According to facility policy, all residents who experience a fall, whether witnessed or unwitnessed, are to receive immediate assessment to determine the extent of injury, including neurological checks if a head injury is suspected. The policy also requires monitoring of vital signs and neurological status as indicated and ordered. In this case, the resident was found on the floor after a thud was heard, with the resident reporting that he did not hit his head but sustained four skin tears on his arm. The clinical record and treatment administration record did not include any post-fall neurological checks for this unwitnessed fall. The resident involved had a history of unsteadiness, abnormal gait, hypertension, and severe cognitive impairment as indicated by a low BIMS score. The care plan identified the resident as being at risk for falls. Despite these risk factors and the unwitnessed nature of the fall, the required neurological assessments were not performed or documented. The DON confirmed during interview that the facility did not provide ongoing neurological assessment after the incident.