Failure to Complete Neurological Assessments After Unwitnessed Falls
Penalty
Summary
The facility failed to complete required neurological assessments following unwitnessed falls for one resident, as outlined in their policy. According to the policy, after an unwitnessed fall or a fall with a potential head injury, staff are to perform neurological assessments at specific intervals: every 15 minutes for 1 hour, every hour for 4 hours, and every 4 hours for 19 hours. Record reviews showed that after multiple unwitnessed falls, staff did not document or complete neurological assessments and/or vital signs at several required times, often noting that the resident was sleeping instead of performing the assessments. The resident involved had significant medical conditions, including non-traumatic brain dysfunction, heart failure, diabetes, Alzheimer's dementia, anxiety, and depression, and was assessed as having severely impaired memory, decision-making, and balance, as well as being dependent on staff for mobility and personal care. Despite these vulnerabilities, neurological assessments were omitted after several unwitnessed falls, with documentation gaps noted on multiple occasions. An RN confirmed that these assessments should not be skipped unless the resident was out of the building.