Failure to Perform and Document Neurological Checks After Resident Fall with Head Injury
Penalty
Summary
A resident with multiple complex medical conditions, including a history of repeated falls, dementia, cerebral infarction, and use of anticoagulant medication, experienced a fall in her room resulting in a head injury with significant bleeding. Upon discovery, a registered nurse performed a head-to-toe assessment and checked vital signs, but did not conduct or document a neurological assessment as required by the facility's policy. The resident was subsequently transferred to the hospital for treatment of a subdural hemorrhage and later returned to the facility, but neurological assessments were still not performed or documented upon her return. Facility policy mandates neurological evaluations following any fall with a head injury or unwitnessed fall, with specific intervals for ongoing checks and documentation. The administrator confirmed that nurses are expected to follow these protocols and acknowledged that no neurological exams were completed or documented for the resident after the incident. Review of the relevant policies further confirmed the requirement for neurological checks and documentation in such situations, which was not followed in this case.