Failure to Complete Required Neurological Checks After Unwitnessed Fall
Penalty
No penalty information released
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Summary
A deficiency occurred when staff failed to properly monitor a resident after an unwitnessed fall. The resident, who had a history of stroke, was found on the floor next to their bed after their roommate activated the call light. The resident was unable to recall how they ended up on the floor or whether they struck their head. Facility protocol required neurological checks to be performed at specific intervals following an unwitnessed fall, but only one neurological assessment was documented in the clinical record. Interviews with staff confirmed that neurological assessments were expected to be completed and documented, but this was not done for the resident involved.