Failure to Follow Post-Fall Protocols and Complete Neurological Assessments
Penalty
Summary
The facility failed to follow its post-fall protocol for two of ten sampled residents, resulting in deficiencies related to fall prevention and post-fall neurological assessments. For one resident, after experiencing two falls within a short period, the facility did not implement additional fall prevention interventions or document a rationale for maintaining the current approach, as required by the facility's policy. The resident's care plan was only revised after a third fall, and there was no evidence that new interventions were considered or implemented following the second fall. Additionally, the same resident did not receive post-fall neurological assessments as ordered by the physician. Although a 72-hour neurological assessment was ordered after a fall, the facility only completed assessments for 48 hours, and one scheduled assessment was missed after the resident returned from the hospital. The documentation did not show that the full 72-hour assessment period was completed as required by the physician's order. A second resident also experienced falls and had physician orders for 72-hour post-fall neurological assessments on two occasions. In both instances, the facility only completed neurological assessments for 48 hours instead of the ordered 72 hours. Furthermore, some assessments were not completed at the scheduled times, with delays and missed assessments documented. These failures were confirmed by facility staff during interviews and record reviews.