Failure to Perform Timely Neurological Assessments After Alleged Head Injury
Penalty
Summary
Registered Nurse (RN) 1 did not perform neurological assessments (neuro-checks) at the required frequency and intervals for a resident who was allegedly struck on the head by a male Certified Nursing Assistant (CNA). The resident, who had severe cognitive impairment, quadriplegia, a tracheostomy, and a gastrostomy, was dependent on staff for all activities of daily living and mobility. Following the alleged incident, neuro-checks were ordered to be performed every 30 minutes, then hourly, as documented in the resident's record. However, the neuro-checks were not conducted at the scheduled times, with some checks being significantly delayed and others performed in rapid succession, not adhering to the required intervals. The Director of Nursing (DON) confirmed that the neuro-checks were not performed according to the ordered schedule and emphasized the importance of timely assessments to identify any changes or complications. The facility's policy and procedure for neurological assessments required staff to perform neuro-checks at the frequency ordered, but this was not followed in this case. The failure to adhere to the neuro-check schedule was documented in the resident's records and acknowledged by the DON during the investigation.