Failure to Complete Neurological Evaluations and Incident Follow-Up After Resident Falls
Penalty
Summary
The facility failed to adequately assess and document resident falls in accordance with acceptable standards of practice and its own policies. Specifically, staff did not consistently complete neurological evaluations, which include assessments such as pulse, respiration, blood pressure, pupil size and reactivity, and hand grip strength, for residents who experienced unwitnessed falls or incidents involving head injury. This deficiency was observed in three residents, all of whom had significant cognitive impairments and multiple comorbidities, including Alzheimer's disease, Parkinson's disease, stroke, and end-stage renal disease. In addition to incomplete neurological checks, the facility did not ensure that incident follow-up (IFU) documentation was completed for 72 hours post-fall in the progress notes for each shift, as required by facility policy. Multiple instances were noted where IFU documentation was missing for both day and night shifts following falls. The records showed gaps in documentation for several days after falls, despite the residents being at high risk due to their medical conditions and history of previous falls. Interviews with nursing staff, the Administrator, and the DON confirmed that the expected protocol was to perform full assessments, complete neuro checks for unwitnessed falls or head injuries, notify appropriate parties, and document all findings and notifications in the nursing notes and incident reports. However, the review of medical records and progress notes demonstrated that these procedures were not consistently followed, resulting in incomplete assessments and documentation for the affected residents.