Failure to Complete Neuro Checks and Bowel Management Interventions
Penalty
Summary
The facility failed to implement required neurological checks following unwitnessed falls for two residents. For one resident with a history of infection, myasthenia gravis, and impaired mobility, neurological checks were ordered after an unwitnessed fall, but several scheduled assessments were missed over multiple days. Documentation confirmed that these checks were not completed as expected, and there was no additional evidence of the assessments being performed. Another resident, who was severely cognitively impaired, required extensive assistance with activities of daily living, and was receiving hospice care, experienced two unwitnessed falls. Record review and staff interviews confirmed that neurological checks were not conducted after either incident, despite facility policy requiring such assessments for unwitnessed falls. Additionally, the facility did not monitor or intervene appropriately for bowel management for the same cognitively impaired resident. Bowel records showed extended periods without a bowel movement, and the Medication Administration Record indicated that no PRN bowel medications were administered during these times. Staff interviews confirmed that the resident should have received PRN bowel medications according to facility policy, but this did not occur.