Failure to Complete Neurological Checks After Multiple Unwitnessed Falls
Penalty
Summary
The facility failed to follow its own policy regarding neurological checks after unwitnessed falls for a resident with significant risk factors, including a history of subdural hematoma, atrial fibrillation, and use of anticoagulation. The resident was identified as being at risk for falls due to confusion and disorientation, and the care plan included interventions for fall prevention. On the day in question, the resident experienced multiple unwitnessed falls, each requiring neurological assessments as per facility protocol. After the first unwitnessed fall, neurological checks were initiated and documented at the required intervals. However, following a second unwitnessed fall, the neurological checks were not restarted as required by facility policy. Instead, the checks continued at the previous schedule, resulting in missed assessments at the mandated half-hour intervals after the second fall. Staff interviews confirmed that the expectation was to initiate a new set of neurological checks after each unwitnessed fall, but this was not done after the second incident. Documentation review and staff interviews further revealed that the neurological assessment protocol was not consistently followed after subsequent falls. The Director of Nursing confirmed that the facility policy required neurological checks to be restarted after each unwitnessed fall, but this was not adhered to in this case. The medical record lacked evidence of the required frequency of neurological checks after the second fall, and staff were not aware that the protocol had not been followed as outlined in the facility's neurological assessment form.