Failure to Complete Neurological Checks After Resident Falls with Injury
Penalty
Summary
The facility failed to complete neurological checks for a resident following two separate falls with injuries. The resident, who had diagnoses including dementia, degenerative disease of the nervous system, major depressive disorder, and generalized anxiety disorder, experienced a fall on 06/05/25 and another incident on 06/06/25 in which she was pushed by another resident, resulting in her hitting the back of her head and sustaining a laceration. After the second incident, the resident was transferred to the hospital, where she was found to have a 2.5-centimeter contusion to the left posterior occiput and received medical glue for the wound. Upon the resident's return to the facility, there was no evidence that neurological checks were performed as required, despite the resident likely having a concussion and orders for continued monitoring. The deficiency was confirmed through record review and interview with the Licensed Nursing Home Administrator, who verified the absence of documentation for neurological checks after the resident's return from the hospital. This issue was identified during a complaint investigation and affected one resident out of six reviewed for incidents with injuries.