Missed Neurological Assessments After Resident Fall
Penalty
Summary
The facility failed to complete neurological assessments according to protocol for a resident who experienced an unwitnessed fall and sustained a head injury. The resident, who had diagnoses including Parkinson's Disease, muscle weakness, and severely impaired cognition, required neurological checks as ordered by the physician following the incident. The protocol specified a detailed schedule for neurological assessments, but review of the Neurological Assessment Flowsheet revealed that 11 assessments were missed over several days. Documentation showed that the assessments were not performed at the required intervals, and some scheduled checks were omitted entirely. During interviews and record reviews, the LVN responsible for the assessments was unable to explain the discrepancies in documentation and timing. The DON confirmed that the neurological assessment schedule was not followed as outlined in the facility's policy and the physician's orders. The facility's policy emphasized the importance of conducting neurological checks as frequently as ordered to monitor for changes indicative of neurological injury. This failure resulted in incomplete and incorrect neurological assessments for the resident after the fall.