Failure to Complete Required Neurological Assessments After Resident Fall
Penalty
Summary
A resident with severe cognitive impairment, as indicated by a BIMS score of 4, and multiple diagnoses including non-Alzheimer's dementia, hypertensive urgency, pneumonia, adult failure to thrive, and dysphagia, experienced a fall in her bedroom after attempting to transfer from bed to the commode. The care plan for this resident identified her as being at risk for falls and included specific interventions such as not leaving her alone on the toilet/commode, keeping walkways clear, and applying nonskid strips. Despite these interventions, the resident was left alone and subsequently fell while transferring. Following the fall, the facility's protocol required a licensed nurse to perform neurological evaluations at specified intervals over a 72-hour period, with documentation on a Neurological Evaluation Form. However, staff failed to complete and document several required neurological assessments at multiple scheduled times. The Interim DON confirmed that the neurological checks were not performed as required, and the clinical record review showed missing entries for the mandated assessments.