Failure to Initiate Neurological Checks After Unwitnessed Fall
Penalty
Summary
A deficiency occurred when a resident with a history of falls, diabetes, high blood pressure, cerebrovascular disease, and normal pressure hydrocephalus experienced an unwitnessed fall. The resident, who had moderately impaired cognition and was on antiplatelet therapy, was found on the floor beside her bed. According to the facility's policy, neurological checks are required for all unwitnessed falls or if a resident hits their head. However, the nurse on duty did not initiate neurological checks after the fall, assuming the resident had not hit her head based on her position and physical examination. Interviews with facility staff, including the DON, ADON, and the nurse involved, confirmed that neurological checks were not started as required by policy. The DON and ADON both stated that neurological checks should have been initiated immediately following the unwitnessed fall, and the failure to do so could result in missing a change in the resident's condition. The facility's policy clearly outlines the need for neurological checks in such situations, but this protocol was not followed in this instance.