Failure to Complete and Document Neurological Monitoring After Unwitnessed Fall
Penalty
Summary
The facility failed to ensure timely and complete neurological monitoring following an unwitnessed fall involving a resident with diagnoses including Parkinson's disease, cervicalgia, and bipolar disorder. The resident, who was cognitively intact and independently ambulatory, was found outside the facility after an apparent elopement attempt. Initial assessments documented that the resident denied head injury and pain, and neurological checks were performed prior to the resident's transfer to the hospital. Upon return from the hospital, documentation of required neurological monitoring was missing for several hours, and the monitoring schedule was not followed as per facility standards. Further review revealed that neurological assessments were not resumed or documented upon the resident's return, despite the expectation for hourly checks to continue. The nurse responsible stated that vital signs were taken and the resident refused neurological monitoring at one point, but this refusal was not documented. Additionally, the nurse did not recall completing or attempting the required neurological assessments at the scheduled times, and documentation inaccurately indicated the resident was still hospitalized during periods when the resident was present in the facility. The facility lacked a clear policy or procedure directing staff on when to conduct post-fall neurological monitoring, relying instead on electronic medical record prompts. The Director of Nursing confirmed that neurological monitoring should have resumed upon the resident's return and continued for 72 hours, but acknowledged that the facility did not have a written policy to guide staff. The deficiency was identified through clinical record review, facility documentation, and staff interviews, which confirmed the failure to complete and document neurological assessments as required.