Failure to Perform and Document Post-Fall Assessments and Neurochecks
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice for two residents by not performing and documenting required assessments following fall incidents. For one resident with a history of heart failure, dementia, psychosis, and repeated falls, staff did not take or document vital signs after a witnessed fall that resulted in a laceration above the right eyebrow. Additionally, neurological assessments (neurochecks) were not performed or documented after multiple falls, despite facility policy requiring such assessments following any fall involving head trauma or unwitnessed falls. Interviews with facility staff, including the Performance Improvement Quality Improvement Nurse, Risk Management Nurse, and Director of Nursing, confirmed that vital signs and neurochecks are essential components of post-fall assessment. The staff acknowledged that these assessments were not completed or documented as required. The facility's policies specify that vital signs must be included in the assessment and communicated to the physician after any change in condition, such as a fall, and that neurochecks must be performed and documented for 72 hours following any unwitnessed fall or fall with head injury. A second resident, admitted with diagnoses including atherosclerotic heart disease, Alzheimer's disease, and osteoporosis, also experienced falls for which neurochecks were not performed or documented, even when the falls resulted in injury and required transfer to an acute care hospital. Review of the facility's policies and interviews with staff confirmed that these omissions were contrary to established procedures. These failures had the potential to delay care and services for both residents.