Failure to Initiate Neurological Assessments After Unwitnessed Resident Altercation
Penalty
Summary
The facility failed to initiate neurological assessments for two residents following an unwitnessed resident-to-resident physical altercation involving alleged head injuries. Both residents had cognitive impairments and complex medical histories, including dementia and encephalopathy. After the incident, one resident was observed crying and covering a reddened left eye, while the other was noted to be in emotional distress. Both residents reported being struck in the face with a sandal during the altercation, but no neurological assessments were performed or documented for either individual. Interviews with nursing staff and the Director of Nursing confirmed that the facility's policy required immediate neurological assessments for any unwitnessed head or facial injury, regardless of visible trauma. The staff acknowledged that neurological checks should have been initiated and documented according to the facility's protocols, which specify frequent monitoring intervals and comprehensive documentation in the medical record. However, record reviews revealed that no such assessments were conducted or recorded for either resident following the incident. The facility's own policies, including the Neurological Assessment and Fall Management Program, outlined the necessity and frequency of neurological checks after suspected head injuries. Despite these clear guidelines, the required assessments were not performed, and the absence of documentation was confirmed through both record review and staff interviews. This failure to follow established procedures constituted a deficiency in the standard of care provided to the residents involved in the altercation.