Failure to Monitor Neurological Status After Resident Assault
Penalty
Summary
The facility failed to monitor a resident for signs and symptoms of neurological decline after the resident was struck on the face by another resident. The affected resident had a history of human immunodeficiency virus disease, morbid obesity, schizophrenia, and bilateral knee contractures, and was noted to have fluctuating capacity for decision-making and moderately impaired cognitive skills. After the incident, the resident was found with a five-centimeter laceration above the left eyebrow, minimal bleeding, and swelling. The resident was transferred to a general acute care hospital and later returned to the facility the same day. Despite the incident and the resident's return from the hospital, staff did not continue neurological checks or monitor the resident's neurological status. Interviews with nursing staff and the Director of Nursing confirmed that neurological assessments were not performed after the resident's return, even though such monitoring was recognized as necessary due to the potential for serious brain injury following facial trauma. The lack of post-incident neurological monitoring constituted the identified deficiency.