Failure to Initiate Neuro Checks and Notify Physician After Unwitnessed Fall
Penalty
Summary
Nursing staff failed to respond appropriately to an unwitnessed fall involving a resident with a history of hypertensive encephalopathy, hypertensive emergency, and recent falls. The resident, who had moderate cognitive impairment and was assessed as high risk for falls, experienced an unwitnessed fall in the bathroom after attempting to get up without assistance or a walker. Although the resident complained of back pain and later of headaches, neurological checks were not initiated as required for unwitnessed falls, and the physician was not notified of the incident or the resident's change in condition. Documentation and interviews revealed that the resident's blood pressure was significantly elevated following the fall, and the resident became increasingly lethargic and unresponsive over the next several hours. Despite repeated complaints of headache and abnormal vital signs, staff did not perform neurological assessments or notify the physician until the resident's condition deteriorated further. The facility's policies required neuro checks and immediate notification of the physician and responsible party for unwitnessed falls and significant changes in condition, but these protocols were not followed by the staff involved. The failure to initiate neuro checks and notify the appropriate parties after the unwitnessed fall was confirmed through record review, staff interviews, and review of facility policies and training records. The resident was eventually transferred to the hospital after being found unresponsive, where imaging revealed new subdural hematomas. The resident subsequently died as a result of the injuries sustained from the fall.