Failure to Complete Neurological Checks After Unwitnessed Falls
Penalty
Summary
Facility staff failed to complete neurological checks in accordance with facility policy and procedure for two residents who experienced unwitnessed falls. The facility's policy required specific neurological assessment protocols, including frequent monitoring and documentation of vital signs and neurological status after any unwitnessed fall or suspected head injury. Despite these requirements, documentation revealed that neurological checks were either incomplete or missing for both residents following their respective falls. One resident, with a history of stroke, altered mental status, abnormal gait, and previous falls, experienced an unwitnessed fall. The resident was found on the floor without apparent injury, and the physician assistant ordered neuro checks per facility protocol. However, only a few neuro checks were documented, and not all included vital signs as required. The documentation did not reflect completion of the full neuro check schedule outlined in the facility's policy. Another resident, with diagnoses including congestive heart failure, kidney failure, diabetes, muscle weakness, and a history of falls, also experienced multiple unwitnessed falls. In each instance, the physician ordered neuro checks per protocol, but documentation showed that only one or a few neuro checks were completed, with significant gaps in the required monitoring schedule. Interviews with staff confirmed that neuro checks should have been performed and documented according to the established protocol, but this was not done.