Failure to Complete and Document Neurological Assessments and 15-Minute Safety Checks Post-Fall
Penalty
Summary
The facility failed to ensure that neurological assessments were completed as required following a resident's unwitnessed fall. According to facility policy, neurological assessments should be performed for 48-72 hours post-fall, but documentation showed that assessments for the resident in question were only completed for approximately 15 hours. Staff interviews and record reviews confirmed that the neurological assessment forms were not completed or dated beyond the initial period, and the expected protocol for continued monitoring was not followed. Additionally, the facility did not ensure that 15-minute safety checks, which were ordered by a physician for the resident due to fall risk, were consistently documented. Although staff stated that these checks were performed and documented on specific forms, there was no evidence in the electronic health record (EHR) to confirm that the checks were completed as ordered. Staff interviews revealed uncertainty about the location and completion of the documentation forms, and a review of the EHR did not show any record of the 15-minute interval checks during the relevant period. The resident involved had a history of dementia, falls, and venous thrombosis and embolism, and was identified as being at high risk for falls and injury. The lack of complete neurological assessments and missing documentation of 15-minute checks following an unwitnessed fall and during a period of increased risk constituted a failure to follow facility protocols and physician orders for monitoring and documentation.