Failure to Complete Neurological Assessments After Resident Fall
Penalty
Summary
The facility failed to follow its Neurological Post-fall Assessment Protocol for a resident who experienced a witnessed fall and struck their head on the edge of the bed. According to the facility's policy, staff are required to initiate and document neurological assessments at specific intervals following a head injury. However, after the incident, no neurological assessments were completed or documented for the resident, and there was no provider order to discontinue these assessments. Interviews with the Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that the resident was sent to the hospital due to suspected stroke-like symptoms and received a negative CT scan. Despite this, the facility did not obtain an order to discontinue the required neurological assessments, nor did they perform or document the assessments as outlined in their policy. The deficiency was identified through record review, policy review, and staff interviews.