Failure to Complete and Document Post-Fall Neurological Assessments
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice by not performing and documenting post-fall neurological assessments and completing post-fall assessments according to its own policy for a resident with a history of multiple falls. The facility's Fall Management policy required a complete neurological evaluation after unwitnessed falls or potential head injuries, as well as post-fall evaluation and documentation on every shift for 72 hours. However, review of the resident's records showed that, following several unwitnessed falls, neurological checks and every-shift documentation were either missing or incomplete for the majority of required intervals. The resident involved had moderately impaired cognition, was frequently incontinent, required substantial to maximal assistance for activities of daily living, and used a wheelchair. The care plan identified the resident as being at risk for falls due to confusion, deconditioning, and gait/balance problems, with multiple falls documented over a two-month period. Despite these risks and repeated incidents, the facility did not consistently document the required post-fall neurological assessments or every-shift follow-up as outlined in their policy. Interviews with staff, including an LPN, the Administrator, the DON, and a Corporate Nurse, confirmed that neurological checks were expected to be completed and documented per policy after unwitnessed falls. The Administrator acknowledged that neurological check sheets for the resident could not be found, and staff had only documented that checks were done without providing the required detailed documentation. This lack of adherence to policy and incomplete documentation constituted the deficiency identified by surveyors.