Failure to Complete Required Neuro Checks and Update Care Plan After Resident Fall
Penalty
Summary
A resident with severe cognitive impairment and multiple medical diagnoses, including acute metabolic encephalopathy, myxedema coma, hypothyroidism, and UTI, experienced a fall from bed that resulted in injury. The fall was unwitnessed, and the resident was found on the floor entangled in bedding, with a dark bruise observed on the right temporal region. Facility policy required a specific schedule of neurological checks following such an event, but only 5 out of the 15 required checks were completed, as confirmed by record review and staff interview. Additionally, the Interdisciplinary Team (IDT) identified the need for a bolster mattress as an intervention to help prevent future falls. However, this intervention was not added to the resident's care plan. The Director of Nursing verified that both the neurological checks and the care plan update were not completed in accordance with facility policy and IDT recommendations.