Failure to Ensure Nursing Staff Competency in Neurological Assessment and Emergency Response
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies and skills to provide safe and appropriate care for residents with complex medical needs, particularly those with neurological impairments. Multiple licensed staff did not demonstrate competency in performing and documenting neurological assessments, identifying medical emergencies requiring timely intervention, or using critical thinking to determine the need for thorough assessments after a fall with potential head or neck injury. Documentation revealed that after a resident with a history of traumatic brain injury, craniectomy, and quadriplegia sustained a fall, staff did not complete full neurological assessments, including level of consciousness and pupillary response, as required by facility policy and standard care protocols. The resident, who had a baseline of neurological impairment and communicated by blinking, experienced a fall from bed while being changed by a CNA. Initial and subsequent nursing documentation focused primarily on vital signs, with incomplete or missing neurological assessment data. Staff failed to consistently document or perform assessments of the resident's level of consciousness and pupil response, and did not recognize or act upon significant changes in the resident's condition in a timely manner. There was a delay in notifying the physician and transferring the resident to a higher level of care, despite clear evidence of altered mental status and neurological decline. Interviews and record reviews indicated that staff were unclear about the components and frequency of neurological assessments, lacked access to necessary equipment such as penlights, and had not received adequate training or competency validation in these areas. The facility's policies lacked specificity regarding post-fall neurological assessments, and there was no evidence of structured training or competency checks for staff involved in the resident's care. The deficiency was determined to be immediate jeopardy due to the involvement of multiple staff and the serious nature of the failures.