Failure to Timely Document Fall and Initiate Neurological Assessments
Penalty
Summary
The facility failed to document a fall and initiate neurological assessments in a timely manner for a resident who was severely cognitively impaired and had multiple diagnoses, including stroke, heart failure, hypertension, dementia, anxiety, and depression. The resident, who used a walker and required staff assistance for ADLs, experienced an unwitnessed fall during the night shift. After the fall, the CNA alerted the nurse, who checked the resident's vital signs and assisted her back to bed. The resident subsequently complained of pain multiple times, but the nurse only checked vital signs and provided medication, without immediate documentation or a thorough assessment. The nurse did not complete the required risk management form for the unwitnessed fall until the following day, and the neurological assessment was not started until over an hour after the incident. Facility policy required immediate assessment and documentation following any fall, including a head-to-toe assessment, pain assessment, and timely initiation of neurological checks. The delay in both documentation and neurological assessment constituted a failure to follow established protocols for post-fall management.