Failure to Initiate Neurological Assessments After Unwitnessed Fall
Penalty
Summary
A resident with severe cognitive impairment, high fall risk, and on daily aspirin for anticoagulation was found sitting upright on the floor after an unwitnessed fall. The resident was unable to communicate the circumstances of the fall or whether a head strike occurred. Despite facility protocol requiring neurological assessments after any unwitnessed fall, especially for residents on anticoagulants, nursing staff did not initiate or conduct neurological assessments following the incident. The Unit Manager relied on the roommate's statement that no head strike occurred and did not perform the required assessments, even though the resident's medical record showed no documentation of such evaluations. Interviews with the Unit Manager, Director of Staff Development, and DON confirmed that it was facility protocol to perform neurological assessments after any unwitnessed fall, regardless of witness statements. The DON acknowledged that, although there was no specific written policy, the expectation was clear among leadership that neurological assessments should be completed for 72 hours post-fall. The failure to follow this protocol was confirmed by the absence of documentation in the resident's medical record and by staff interviews.