Failure to Complete Timely Neurological Monitoring After Unwitnessed Fall
Penalty
Summary
A deficiency occurred when the facility failed to complete timely neurological monitoring after an unwitnessed fall involving a resident with chronic obstructive pulmonary disease, morbid obesity, and heart failure. The resident, who was non-ambulatory and used a wheelchair, experienced a fall in the elevator after being pushed by another resident. The fall resulted in a nasal bone fracture and facial laceration, requiring hospital evaluation and treatment. Facility documentation, including the Neurological Check Sheet and nursing notes, lacked evidence that neurological assessments were performed as required by facility policy in the period following the fall and prior to the resident's transfer to the hospital. The facility's policies directed neurological checks at specific intervals after unwitnessed falls or suspected head injuries. However, the neurological assessment form was incomplete, with missing entries for vital signs, hand grasps, level of consciousness, pupil response, and nurse initials for the required time points. Interviews with facility leadership confirmed that neurological assessments should have been completed and documented, but no such documentation was available for the period before EMS arrival or for two of the required four-hour assessments. The failure to perform and document neurological checks was not in accordance with the facility's established protocols.