Failure to Obtain Daily Weights and Perform Neurological Checks After Fall
Penalty
Summary
Facility staff failed to obtain daily weights as ordered for a resident with a diagnosis of heart failure. The resident's Medication Administration Record (MAR) for July and August showed multiple days where daily weights were not recorded, despite a physician's order requiring daily weights and notification if the resident gained more than 3 pounds in a day or 5 pounds in a week. The resident required varying levels of assistance with activities of daily living and was assessed as cognitively intact. The Corporate Nurse confirmed that daily weights were not conducted as required. Additionally, the facility did not implement neurological evaluations after an unwitnessed fall for another resident who had moderate cognitive impairment and required substantial to total assistance with mobility and personal care. The resident's care plan documented an unwitnessed fall, but there was no evidence in the health record that neurological checks were performed following the incident. The Corporate Nurse confirmed that neurological evaluations were not completed as per facility policy, which requires such assessments after unwitnessed falls where a head injury is suspected.