Failure to Complete and Document Ordered Neuro-Checks and Vital Signs
Penalty
Summary
Facility staff failed to perform and document neuro-checks and vital signs as ordered by a medical provider for one resident following a fall. The resident, who had severe cognitive impairment as indicated by a Brief Interview for Mental Status (BIMS) score of 5 out of 15, had provider orders for neuro-checks and vital signs every four hours. Documentation on the medication administration record (MAR) showed that these assessments were not completed at the 4:00 a.m. interval, with staff noting the resident was sleeping instead. No assessment findings or data for this missed check were found or provided to the surveyor. Facility policy required that neuro-checks be performed and documented as ordered, including specific neurological and vital sign assessments. During interviews, the Director of Nursing confirmed that the resident should have been woken up to complete the required assessments. The failure to complete and document the neuro-checks and vital signs as ordered was discussed with facility leadership during surveyor meetings.