Failure to Consistently Perform and Document Neurological Checks After Resident Fall
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including metabolic encephalopathy, unsteadiness, cognitive impairment, and on anticoagulant therapy, experienced an unwitnessed fall during the night. The resident struck her head on a counter while returning from the bathroom. Initial assessments were performed, including vital signs and application of ice to the injury site, and the provider was notified. Orders were received to document the resident's condition in progress notes every shift for three days and to conduct neurological checks. Despite these orders, neurological checks were inconsistently performed. Documentation shows that after the initial neuro checks at 3:00 am, the resident refused several subsequent checks, but the checks were resumed at 7:45 am and 8:45 am. There is no evidence that neurological checks continued after 8:45 am as ordered, and the resident was sent to the hospital at 9:45 am. The facility's policy and staff interviews confirm that neuro checks should be initiated and continued as ordered, with refusals documented and the provider notified. However, the documentation does not indicate that the provider was notified of the resident's repeated refusals or that neuro checks were consistently attempted and documented as required. The failure to follow physician orders for ongoing neurological assessment after a head injury, especially in a resident on anticoagulant therapy, represents a lapse in providing care according to professional standards. The facility's own policies require thorough assessment and documentation following a fall, particularly when the resident is at increased risk for complications. The lack of consistent neuro checks and incomplete documentation of refusals and provider notifications led to the identified deficiency.