Failure to Complete and Document Post-Fall Neurological Assessments
Penalty
Summary
The facility failed to meet professional standards of quality by not completing required neurological assessments for two residents following falls, as identified through record review and staff interviews. For one resident with a history of stroke who sustained a fall resulting in a head laceration and required sutures, there was no evidence that the facility's neurological assessment protocol was initiated after the resident returned from the emergency room, despite provider recommendations and facility policy requiring such assessments for head injuries or unwitnessed falls. The Assistant Director of Nursing was unable to provide documentation that the neuro checks were completed as required. For another resident with dementia who experienced an unwitnessed fall, the facility's neurological evaluation flow sheet indicated that assessments were to be performed at specific intervals following the incident. However, documentation was missing for all required assessment times within the first two hours post-fall. The Assistant Director of Nursing confirmed that the neurological evaluation was not completed in its entirety and acknowledged that staff did not document the assessments as expected per facility policy.