Failure to Timely Document Neurological Assessment Following Stroke Concern
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to document a neurological assessment for a resident who was suspected of having a stroke. The resident, who had a history of stroke, chronic kidney disease, type 2 diabetes, and atrial fibrillation, was reported by a friend to be experiencing stroke symptoms, including slurred speech and facial droop. The RN assessed the resident for neurological symptoms on the evening of the reported concern but did not record the assessment in the medical record at the time it was performed, as required by facility policy. The omission was discovered during a surveyor's review of the resident's medical record, which revealed no documentation of the neurological assessment prior to the resident's subsequent hospital transfer. The RN later confirmed that the assessment had been completed but was not documented until prompted by the Director of Nursing (DON) several days later. The DON verified that the assessment should have been documented at the time of service, in accordance with facility policy.