Failure to Complete 72-Hour Post-Fall Neurological Assessments
Penalty
Summary
The facility failed to complete post-fall neurological assessments for the required 72-hour period for two of five residents reviewed for accidents. According to the facility's Fall Management Program policy, for unwitnessed falls, neurological assessments are to be conducted every 15 minutes for one hour, every 30 minutes for one hour, every hour for four hours, and then every four hours until 72 hours post-fall. For one resident, after a fall from bed while reaching for a dropped water pitcher, neurological checks were only performed for 41 hours, and staff did not realize the assessments had not continued for the full 72 hours as required. The neurological flow sheet was marked as completed, but the checks did not extend to the full duration specified in the policy. For another resident who was found lying on the floor, neurological assessments were conducted for only 50 hours instead of the required 72 hours. Staff interviews confirmed that the post-fall neurological checks were not completed for the full duration as outlined in the facility's protocol. In both cases, the documentation and staff statements verified that the assessments were prematurely discontinued, contrary to the established policy for post-fall care.