Failure to Perform Timely and Accurate Neuro Checks After Falls
Penalty
Summary
Facility staff failed to properly perform neurological checks after falls for two residents, as required by facility protocol. One resident, admitted with a history of falls, experienced an unwitnessed fall in the bathroom. Although the provider was notified and recommended monitoring per protocol, staff did not complete neuro checks at the required intervals and, in some instances, used outdated vital signs. Several scheduled neuro checks were missed, and the night shift did not complete the required assessments. Another resident, admitted with weakness, had an unwitnessed fall and was found sitting between the bed and wall. The provider instructed staff to follow the facility's neuro check protocol, but staff again failed to perform neuro checks at the correct intervals, omitted some checks, and used vital signs from several hours prior. Interviews with nursing leadership confirmed that neuro checks were not completed accurately or according to the established schedule for both residents.