Failure to Complete Required Neurological Assessments After Unwitnessed Fall
Penalty
Summary
The facility failed to provide the highest practicable care regarding neurological assessments for a resident who experienced an unwitnessed fall. According to facility policy, neurological assessments are required following such incidents, with specific intervals for monitoring and documentation. The resident was found face down on the bathroom floor with lacerations to both elbows. The registered nurse assessed the resident's neurological status and contacted the on-call physician, who provided instructions regarding medication and monitoring for changes in neurological status. The nurse documented neurological assessments at 9:30 PM, 10:00 PM, 10:30 PM, and 11:00 PM, but no further assessments were recorded at the required intervals throughout the night. Review of the resident's clinical record and facility investigation confirmed that neurological assessments were not documented at 12 AM, 1 AM, 3 AM, and 5 AM, as required by facility policy. Staff interviews verified that the established protocol for post-fall neurological monitoring was not followed. The resident was later found deceased in the early morning hours, with the death certificate citing chronic diastolic heart failure as the main cause of death. The deficiency was confirmed by both nursing staff and the Nursing Home Administrator.