Failure to Complete Neurological Assessments After Unwitnessed Falls
Penalty
Summary
The facility failed to complete neurological assessments as required by its own policy following unwitnessed falls for two residents. The policy, last revised in October 2010, mandates neurological checks after unwitnessed falls, falls with suspected head injury, or when indicated by resident condition. These checks include assessments of orientation, speech, vital signs, pupil reactions, and motor ability, and must be documented in the resident's medical record with specific timing and details. Staff interviews confirmed that the protocol was not followed, and the Director of Nursing acknowledged the lapses. One resident with severe cognitive impairment, multiple diagnoses including heart disease and dementia, and on anticoagulant therapy, experienced several unwitnessed falls. For each incident, required neurological assessments at specified intervals (every 15 minutes, 30 minutes, hourly, and per shift) were missing from the documentation. The resident's care plan identified them as high risk for falls and in need of extensive assistance, yet the facility failed to document or perform the required post-fall neurological checks on multiple occasions. Another resident, cognitively intact but with multiple medical conditions and at risk for falls, also experienced unwitnessed falls. After these incidents, the facility failed to complete and document neurological assessments and vital signs as required. Incident reports and post-fall assessment forms showed missing or incomplete documentation for the required checks. The DON confirmed that staff did not follow the facility's neurological assessment protocol after these falls.