Failure to Complete and Document Neurological Assessments and Follow Physician Orders After Resident Injuries
Penalty
Summary
The facility failed to implement physician's orders and complete required neurological assessments for three residents who experienced injuries, specifically head injuries and falls. In one case, a resident fell while moving items in her room, resulting in a head wound requiring stitches and a left arm injury. Although orders were given for a repeat x-ray and an orthopedic follow-up, there was no documentation that these were completed, and neurological assessments were not consistently performed or documented as required. Another resident fell from his wheelchair, sustaining a facial injury and was later diagnosed with a stroke. Despite physician orders for hourly neurological assessments for 12 hours, the documentation did not show that these checks were completed as ordered. The resident was also on medications that could increase bleeding risk, further emphasizing the need for close monitoring, which was not documented. A third resident was found with a bruised and swollen left eye, and neurological checks were initiated. However, the records showed that only a portion of the required assessments were completed, with several scheduled checks missing. The facility's own policy required specific intervals for neurological assessments following head injuries or unwitnessed falls, but these protocols were not followed or documented for the residents involved.