Failure to Complete Post-Fall Neurological Assessments and Timely Wound Care
Penalty
Summary
The facility failed to properly assess and monitor a resident following unwitnessed falls, as well as failed to follow its own Fall Management and Neurological Evaluation policies. Specifically, after two separate unwitnessed falls, the resident did not receive the required neurological assessments for the full 72-hour monitoring period. Documentation showed that only a portion of the required neurological checks were completed, with significant gaps in monitoring after the initial hours post-fall. The facility's policies required frequent neurological checks after any unwitnessed fall or head injury, but these were not consistently performed or documented. Additionally, the facility did not ensure that another resident received appropriate wound care for pressure ulcers upon admission. Despite a hospital wound care note recommending specific wound care orders and a follow-up appointment, there was no evidence that these orders were implemented or that new orders were obtained in a timely manner. Wound care orders were not entered until 13 days after admission, and there was no documentation that the resident was taken to the recommended wound care follow-up appointment. The same resident also required monitoring and care for an indwelling Foley catheter, including regular output measurement and catheter care as outlined in the care plan. However, the clinical record lacked evidence that output was consistently measured and recorded, and there was no documentation of catheter care being performed as required. These deficiencies were confirmed through record review and staff interviews.