Failure to Complete and Document Neurological Checks After Unwitnessed Falls
Penalty
Summary
A deficiency occurred when the facility failed to complete and document neurological checks after an unwitnessed fall for one resident reviewed for falls. The resident, who had diagnoses including encephalopathy, dementia, and adult failure to thrive, was assessed as having moderately impaired cognition and was at risk for falls due to dementia-related forgetfulness and impulsive behavior. The care plan included specific fall prevention interventions, and after two separate unwitnessed falls, nursing notes and physician orders directed that neurological checks be performed per facility protocol. Despite these directives, review of the accident and incident forms, medical records, and facility documentation did not show evidence that neurological checks were completed or documented following either fall. The Director of Nursing Services was unable to provide the required neurological check documentation for the relevant dates. Facility policy required neurological assessments at specific intervals after an unwitnessed fall, but these were not found in the resident's records.