Inaccurate Neuro Check Documentation Following Resident Fall
Penalty
Summary
The facility failed to ensure that a resident's medical record was complete and accurate following an unwitnessed fall. According to the facility's policy, neuro assessments are required after any unwitnessed fall. Review of the resident's 72 Hour Neuro Check - List revealed that the time intervals between neuro checks were not accurately documented. Specifically, after the initial one-hour intervals, the transition to two-hour intervals was not correctly followed, resulting in all subsequent neuro check entries being delayed by one hour. During interviews and concurrent medical record reviews with both an LVN and the DON, it was confirmed that the neuro check documentation contained incorrect time entries. This inaccuracy in the resident's medical record meant that the required neuro assessments were not performed at the correct intervals as outlined in the facility's policy.