Failure to Perform Timely Neuro Checks After Resident Fall
Penalty
Summary
The facility failed to follow recognized standards of care and its own policy regarding post-fall monitoring for a resident who experienced an unwitnessed fall. The resident was found on the floor in his room, confused but redirectable, and had removed his oxygen, which was subsequently replaced. Initial assessments noted confusion and an inability to follow commands, including for pupillary checks. Despite the facility's neuro check policy requiring assessments every 15 minutes for the first hour after an unwitnessed fall, documentation showed that neuro checks were not performed at the required intervals. Specifically, the resident was assessed at 9:15 AM and not again until 9:45 AM, missing the mandated 15-minute checks. The nursing notes indicated that the resident was alert but confused after the fall, with baseline cognition and range of motion, and denied pain. However, the resident was later found unresponsive, and CPR was initiated. The facility's neuro check policy was not followed, as confirmed by both documentation review and staff interviews. The lapse in protocol and documentation was acknowledged by facility leadership during the investigation.