Failure to Complete Neurological Assessments After Unwitnessed Falls
Penalty
Summary
The facility failed to ensure that neurological assessments, including vital signs and neurological checks, were completed following unwitnessed falls for three residents. According to the facility's policy, neurological assessments are required after unwitnessed falls, head trauma, or as indicated by the resident's condition, and should include frequent vital signs. The protocol specifies checks every 15 minutes for one hour, every 30 minutes for one hour, every hour for four hours, and then every four hours for 24 hours. For one resident with mild cognitive impairment and Parkinson's disease, documentation showed an unwitnessed fall with a head injury and subsequent hospital visit. Upon return from the hospital, there was no evidence that neurological checks or vital signs were completed as required by protocol. The DON confirmed that these assessments should have been performed. Another resident, cognitively intact with multiple sclerosis, experienced an unwitnessed fall, but there was no documentation of neurological checks or vital signs following the incident, which was also confirmed by the DON. A third resident, who was cognitively impaired with dementia and had wandering behaviors, also had an unwitnessed fall. Again, there was no documented evidence that neurological assessments or vital signs were completed per protocol after the fall. The DON confirmed the lack of documentation for this resident as well. These findings indicate that the facility did not follow its own policy for post-fall neurological assessments for multiple residents.
Plan Of Correction
Unable to retroactively complete neurological assessment. Resident who had an unwitnessed fall have the potential to be affected. Education provided to licensed nurses on initiating neurological assessment per facility policy with an unwitnessed fall. The Director of Nursing or designee will audit and review incident reports (unwitnessed falls) to ensure neurological assessments have been completed per facility policy with unwitnessed falls. Audits will be conducted as follows: 1.) Up to 4 records will be reviewed daily for 4 weeks. 2.) Then up to 10 records will be reviewed monthly for 2 months. Results of the audits will be provided by the Administrator and be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with the coordination of the interdisciplinary team at QAPI Committee meeting.