Incomplete and Improperly Authenticated Neurological Assessments After Resident Falls
Penalty
Summary
A review of the electronic health record revealed that a resident who had experienced seven falls during their stay did not have properly completed post-fall neurological assessments. Specifically, one assessment scanned into the resident's health record was missing correct dates and lacked the nurse's signature in eight instances. For a fall that occurred at 6:00 PM, the neurological assessment form was missing all four signature slots for the 30-minute checks and all four signature slots for the hourly checks. Additionally, the hourly checks that occurred after midnight were not dated to reflect the correct day the assessments were performed. The administrator confirmed that the neurological assessments were not signed or dated at the required times. The DON also verified that the original form was not completed accurately. These findings indicate that the facility failed to maintain medical records in accordance with accepted professional standards, specifically regarding the documentation and authentication of post-fall neurological assessments for the resident.