Failure to Perform Timely Neurochecks After Resident Head Injury
Penalty
Summary
A deficiency occurred when a resident, admitted with a diagnosis including aphasia, was involved in a resident-to-resident altercation resulting in a blow to the head and new facial bruising. According to the facility's policy, neurological checks (neurochecks) were required to be performed by a licensed nurse immediately after any head injury, with specific intervals for monitoring and documentation. However, the clinical record and interviews revealed that neurochecks were not initiated until approximately four hours after the incident, rather than immediately as required. The licensed nurse involved could not recall if neurochecks were performed, and documentation showed the first set of vital signs and assessments were recorded significantly later than policy dictated. The Director of Nursing confirmed that neurochecks should have been completed immediately following the head injury, and the facility's policy outlined a clear protocol for the frequency and documentation of these assessments. The failure to perform timely neurochecks meant that the resident did not receive care in accordance with professional standards and facility policy following a head injury.