Failure to Complete Required Neurological Assessments After Unwitnessed Falls
Penalty
Summary
The facility failed to ensure proper monitoring and completion of neurological assessments for a resident following two unwitnessed falls. The resident, who had a history of cerebral infarction and encephalopathy, experienced a change in condition and was noted to have fallen on two separate occasions. After the first fall, documentation showed that vital signs were taken and the resident was assessed, but the neurological assessment was incomplete, lacking documentation of pupil and extremity checks, and the falls checklist and CNA post-fall assessment were not completed or signed. Following the second fall, facility policy required neurological checks at specific intervals for unwitnessed falls or suspected head trauma. However, the resident's neurological status was not documented as completed at multiple required times over the subsequent days. Several scheduled neurological checks were either missing or incomplete, and there were gaps in documentation across multiple shifts. Interviews with nursing staff and the DON confirmed that the expected protocol was not followed, and that there were numerous blanks and uncompleted neurological monitoring entries for the resident after both unwitnessed falls. The facility's own policy required thorough assessment and documentation after such incidents, but these procedures were not consistently carried out or recorded in the resident's medical record.