Failure to Complete Neurological Assessments After Resident Falls with Head Impact
Penalty
Summary
The facility failed to complete neurological assessments after two residents experienced falls with head impact, resulting in one resident sustaining a subdural hematoma and requiring hospitalization. In the first case, a resident with multiple medical conditions, including sick sinus syndrome, syncope, and a recent pacemaker placement, fell in the shower room and hit his head on both the wall and the floor. Although the CNA reported the head impact to the LPN, no neurological assessments were performed. The LPN relied on a brief visual and tactile check and the resident's verbal response, but did not conduct or document neurological checks as per facility policy. Approximately 1 hour and 37 minutes after the fall, the resident was found unresponsive and was later diagnosed at the hospital with a large acute subdural hematoma, requiring transfer to a major medical center. In the second case, another resident with a history of unsteadiness, muscle weakness, and cognitive impairment was found on the floor after an unwitnessed fall and reported hitting their head. The resident was sent to the emergency room for evaluation, but no neurological assessments were completed or documented in the electronic health record before or after the transfer. The care plan for this resident identified a high risk for falls, but interventions did not include post-fall neurological checks. The DON stated that neurological checks were not performed because there were no findings on assessment and no provider order for such checks. Facility policy required routine neurological assessments after head injuries to monitor for changes indicative of neurological injury, including assessments of mental status, pupillary response, motor strength, sensation, and gait. Nursing standards also call for frequent neurological checks after a head injury, with the frequency determined by the severity of the injury and any changes in the resident's condition. In both cases, the facility did not follow its own policy or nursing standards, resulting in a failure to provide appropriate post-fall neurological monitoring for residents who had sustained head injuries.