Failure to Document and Complete Required Neuro Checks After Resident Fall
Penalty
Summary
The facility failed to provide fundamental quality of care and adhere to professional standards of practice for one resident who experienced a fall. The resident, who had a complex medical history including glioblastoma with recent craniotomy revision, sepsis, and a diabetic wound, was admitted for rehabilitation and required close monitoring due to his high fall risk. Despite the baseline care plan indicating the need for safety monitoring, including 15-minute safety checks and a 1:1 staff-to-resident ratio, there was no documentation that these safety checks were performed. After the resident was found on the floor, the incident note did not specify what the resident was doing prior to the fall, where he fell from, or provide details of immediate or follow-up neurological checks. Following the fall, the facility's documentation was inconsistent and incomplete. Although the facility's policy required neuro checks if a head injury was suspected or confirmed, and ongoing monitoring for 72 hours post-fall, there was no evidence that these assessments were completed or documented in the resident's medical record. The electronic medical administration record (EMAR) indicated that neuro checks and post-fall monitoring were initiated several hours after the fall, rather than immediately as required. Staff interviews revealed confusion about the completion and documentation of neuro checks, with some staff stating they were done on hard copy sheets, but these could not be located during the survey. The nurse manager and administrator were unable to provide the requested documentation of neuro checks or clarify what post-fall assessments were performed. Family members expressed concern about the resident's condition following the fall, noting increased confusion, shortness of breath, and combative behavior. They reported that staff were not performing the expected neuro checks or responding promptly to call lights. The facility was unable to provide a policy specific to neuro checks and could not produce documentation to show that the required post-fall assessments and monitoring were completed according to facility policy. This lack of documentation and adherence to protocol constituted a failure to provide care in accordance with professional standards and the resident's care plan.