Failure to Complete Required Neurological Assessments After Unwitnessed Falls
Penalty
Summary
The facility failed to properly assess and monitor residents following unwitnessed falls, and did not adhere to its own Fall Management and Neurological Assessment policies. According to the facility's policies, a neurological assessment is required after any unwitnessed fall for residents with a Brief Interview for Mental Status (BIMS) score of 12 or lower, or when a head injury is suspected. However, documentation revealed that for three residents with cognitive impairment, these assessments were either not completed or only partially completed after unwitnessed falls. One resident with a BIMS score of 5 experienced two unwitnessed falls. After the first fall, there was no evidence of a post-fall observation or neurological assessment. Following the second fall, where the resident reported hitting their forehead, only 5 out of the required 15 neurological checks were documented. Another resident with a BIMS score of 11 had an unwitnessed fall and only 3 of the 15 required neurological assessments were completed, despite the policy requirements. The Director of Nursing confirmed that staff did not follow the facility's policy in this case. A third resident, with severe cognitive impairment (BIMS score of 3), had multiple unwitnessed falls in a short period. Documentation showed that after one fall, the resident was sent to the emergency department, but for another fall, there was no evidence of post-fall evaluation or neurological assessments. Neurological assessments were only started after a subsequent fall and were not completed for all required intervals. Facility leadership confirmed the lack of appropriate monitoring and documentation for these incidents.