Failure to Consistently Complete and Document Post-Fall Neurological Assessments
Penalty
Summary
The provider failed to follow nursing professional standards by not ensuring consistent completion and documentation of neurological checks for a resident who fell and hit her head. The incident occurred when a certified nursing assistant (CNA) let go of the resident's gait belt to turn on a bathroom light, resulting in the resident losing balance, falling, and striking her head on the floor. The resident was assessed by an LPN at the time, with no injuries identified, and was subsequently taken to the emergency room by her husband. Upon return to the facility, the resident was diagnosed with mild dehydration and advised to increase fluid intake. A review of the resident's electronic medical record revealed multiple deficiencies in the documentation of post-fall neurological assessments. The neuro assessments were incomplete at several required intervals, with missing documentation in critical areas such as the Glasgow Coma Scale, pupil assessment, ocular assessment, visual acuity, neurological symptoms, and movement/strength/sensation. These omissions occurred repeatedly over several days following the fall, despite the facility's policy and post-fall worksheet specifying the frequency and components required for neurological checks after a head injury. Interviews with nursing staff and facility leadership confirmed that the expectations for completing neuro assessments were unclear, and the electronic medical record system allowed staff to mark the task as complete even when only partial information was entered. Both the infection preventionist and the administrator acknowledged that the neuro assessments were not completed consistently or thoroughly, as required by facility policy. The facility's policies clearly outlined the need for comprehensive and regular neurological assessments following a fall with head impact, but these were not adhered to in this case.