Failure to Complete Neurological Checks per Protocol After Unwitnessed Falls
Penalty
Summary
The facility failed to ensure that neurological checks were completed as indicated in their policy for two residents following unwitnessed falls. For one resident with diagnoses including acute respiratory failure, congestive heart failure, and dementia, the care plan required neuro checks after an unwitnessed fall. However, the neurological assessments were not performed at the required intervals, as the checks were completed every 30 minutes twice, every hour twice, and then every three hours three times, instead of following the specified protocol. Similarly, another resident with diagnoses of pneumonia, meningitis, and mobility abnormalities also experienced an unwitnessed fall. The neurological assessments for this resident were completed at incorrect intervals, deviating from the facility's protocol. The DON confirmed during interview and record review that the neuro checks for both residents were not completed at the correct frequencies as required by the facility's policy and procedure, which mandates specific intervals for neurological assessments following unwitnessed falls.