Failure to Complete Timely Neurological Assessments After Unwitnessed Fall
Penalty
Summary
The facility failed to ensure that neurological assessments were completed in a timely manner following an unwitnessed fall, as required by facility policy. A resident with a history of traumatic brain hemorrhage, severe cognitive impairment, and a high risk for falls experienced an unwitnessed fall and was found on the floor by housekeeping staff. Initial assessments were performed, and the resident was found to have no injuries or pain. However, documentation revealed that neurological checks were not consistently completed every shift for 72 hours post-fall, as directed by the facility's Post Accident & Incident Monitoring Sheet. Only a few assessments were documented, leaving several required checks unaccounted for during the monitoring period. Interviews with nursing staff and the Director of Nursing confirmed that neurological assessments should have been performed and documented every shift for 72 hours following the fall. The Director of Nursing was unable to provide documentation that these assessments were completed according to policy and acknowledged that the required monitoring was not carried out. The deficiency was identified through clinical record review, facility documentation, and staff interviews, which collectively demonstrated a failure to meet professional standards of quality in post-fall monitoring.