Failure to Consistently Monitor and Document Vitals and Neuro Checks After Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident received complete and accurate vital sign monitoring and documentation per physician orders and professional standards of practice. The resident, who had Alzheimer's disease, diabetes, and hypertension, was on two blood thinners (Plavix and Eliquis) and a blood pressure medication (Metoprolol Tartrate). After experiencing a fall in the bathroom and hitting her head, the resident was found with a bump on her head and a skin tear on her right arm. The nurse initiated neuro checks and contacted the provider, but there was no detailed documentation of the head wound in the medical record, and the neuro check documentation was not initially found in the electronic medical record (EMR). Further review revealed that the resident's blood pressure readings were not consistently documented prior to the administration of Metoprolol, as required by physician orders. The Medication Administration Record (MAR) showed the medication was given twice daily, but blood pressure readings were only recorded five times over a two-week period, despite 29 opportunities. This lack of consistent monitoring made it impossible to determine if low blood pressure contributed to the resident's fall. Additionally, the neuro check documentation began 15 minutes after the fall, and vital signs at the time of the fall were not initially available in the EMR. A paper copy of the neuro check sheet with hand-written vitals was later produced, but it had not been previously scanned or included in the EMR. Interviews with nursing staff and the Director of Nursing (DON) confirmed that vital sign monitoring was not consistently performed or documented as required. The DON acknowledged the absence of a detailed skin assessment and the incorrect entry of older vital signs in the change of condition form. The facility's policies required vital sign monitoring prior to medication administration and neurological assessment after falls with suspected head trauma, but these standards were not met in this case.
Plan Of Correction
1.) Resident #64 was assessed and no acute issues were noted. All residents have the potential to be affected. 2.) A one-time review of all guests on hypertensive medications from the last 30 days was completed to ensure hypertensive parameters are being followed. A one-time review of falls within the last 14 days was reviewed to ensure neuro checks were being completed as ordered. 3.) Licensed nurses were re-educated on following parameters on hypertensive medications and on completing neuro checks with unwitnessed falls. System change: The nurse managers will review all new hypertensive medications for parameters if needed and will review all falls to ensure neuro checks were completed for unwitnessed falls. 4.) DON/Designee will review 5 medical records weekly x 12 weeks to ensure that hypertensive medications with parameters are being followed. Any non-adherence will result in 1:1 education. All audits will be taken to the QA committee for review. DON/Designee will review 5 medical records weekly x 12 weeks to ensure that neuro checks were being completed for unwitnessed falls. Any non-adherence will result in 1:1 education. All audits will be taken to the QA committee for review. 5.) The Executive Director is responsible for maintaining compliance with the regulation.