Incomplete Neurological Assessment Documentation After Unwitnessed Falls
Penalty
Summary
The facility failed to maintain complete and accurate medical records for five residents who experienced unwitnessed falls. According to the facility's own policies, any resident who sustains an unwitnessed fall or a head injury is to receive neurological assessments at specific intervals for at least 72 hours following the incident. Upon review, surveyors found that for several residents, either the neurological assessment logs were missing entirely or, when present, were incomplete for the required 72-hour period. Progress notes did not provide explanations for the missing or incomplete assessments. Specifically, two residents had no neurological assessment logs available for their unwitnessed falls, while three residents had logs that were incomplete for the required monitoring period. The facility was unable to produce the missing documentation or confirm that the required neurological assessments were performed as per policy. These findings were confirmed during an interview with the Corporate Representative, who acknowledged the absence of the necessary records.