Failure to Provide Neurological Assessment and Monitoring After Unwitnessed Fall
Penalty
Summary
The facility failed to provide necessary care and services to a resident following an unwitnessed fall with a head injury. According to the facility's Falls - Clinical Protocol, nurses are required to assess and document vital signs, injuries, musculoskeletal function, changes in cognition or consciousness, neurological status, and pain after a fall. However, after the resident was found face down on the floor by staff, there was no documented evidence of neurological assessments or monitoring for changes in condition from the time of the fall through the following morning. Nursing notes and incident reports did not reflect any neuro checks or assessments for potential head injury, despite the resident having severe cognitive impairment and being at increased risk for complications. The resident's daughter discovered significant bruising on the resident's forehead and a swollen, sore right foot the morning after the fall. She reported that staff were unaware of the fall and that there was no documentation in the clinical record regarding the incident or the injuries observed. The daughter had to request that the resident be sent to the emergency room, where hospital records later confirmed a large scalp hematoma and a nondisplaced fracture of the toe. Interviews with staff and review of the clinical record confirmed the absence of required neurological monitoring and documentation following the unwitnessed fall. The deficiency was further substantiated by interviews with the resident's physician and the Director of Nursing, both of whom confirmed that no neuro checks or systematic assessments were performed or documented after the fall. The lack of timely and appropriate assessment and documentation following the unwitnessed fall with head injury constituted a failure to follow facility policy and provide necessary care and services as required by regulation.