Failure to Timely Initiate Neurological Checks After Resident Fall with Head Injury
Penalty
Summary
The facility failed to ensure that a neurological evaluation was promptly initiated after a resident experienced a fall with a reported head injury. The resident involved had severe cognitive impairment and required significant staff assistance for daily activities. On the day of the incident, a State Tested Nursing Assistant (STNA) lowered the resident to the floor after the resident attempted to sit and missed the recliner, during which the resident's head brushed against a bedside table. The STNA reported the incident to two Licensed Practical Nurses (LPNs), indicating that the resident may have brushed her head on the table. Despite this information, neither LPN initiated neurological checks immediately following the fall. Documentation shows that neurological checks were not started until several hours after the incident, following clarification with the facility's Nurse Practitioner. The facility's fall investigation confirmed that there was no documentation of neuro checks being initiated until later in the day, despite the facility's policy requiring neurological assessments after unwitnessed falls or suspected head injuries. Interviews with staff confirmed that the required neurological checks were not performed in a timely manner after the fall.