Failure to Assess, Document, and Notify After Resident Head Injury During Transport
Penalty
Summary
A resident was transported to an orthopedic appointment by the facility's former Maintenance Director, who was not clinical staff. During transport, the resident's wheelchair flipped backwards, causing the resident to hit his head and sustain a scrape. The Maintenance Director did not notify the facility of the incident, relying on the resident's statement that he was fine and the fact that he was at a doctor's office. The resident's daughter discovered the injury at the appointment and contacted the facility, expressing concern about not being informed of the incident. Upon return to the facility, the acting DON/ADON, who had a background in neurology trauma, assessed the resident and determined he was fine but did not document the assessment, perform or document neuro checks, or notify the physician as required by facility policy. The RN assigned to the resident was instructed to perform hourly neuro checks but did not complete or document them, citing being busy with nursing students. The resident's electronic medical record contained no documentation of the incident, neuro checks, or physician notification, despite facility policies requiring such actions following a fall or head injury.