Failure to Complete and Document Post-Fall Neurological Checks
Penalty
Summary
The facility failed to provide treatment and care according to professional standards of practice by not completing and documenting neurological checks (neuro checks) after falls for two residents identified as high fall risks. According to the facility's fall procedure, residents who experience a fall are to be placed on neuro checks for 72 hours, with each check documented in the Neuro Check Binder. For one resident with a history of joint replacement surgery and self-care deficits, an unwitnessed fall occurred while attempting to self-transfer. Although the resident reported back pain and received pain medication, there was no documentation that neuro checks were performed or recorded following the fall. A subsequent progress note indicated that the responsible LPN failed to complete the required neuro assessments. Another resident, admitted with a right femur fracture and dementia, also experienced a fall and was reportedly placed on neuro checks after complaining of significant pain. However, a review of the clinical record revealed no evidence that neuro check assessments were completed or documented. Staff interviews confirmed that neuro checks were not always performed due to time constraints, and the medical records staff verified the absence of documentation for both residents. The administrator and director of nursing services acknowledged that the post-fall neuro check procedures were not followed for these residents.