Failure to Complete Head Trauma Protocol After Unwitnessed Fall
Penalty
Summary
The facility failed to ensure completion of the Head Trauma Protocol following an unwitnessed fall for one resident. According to the facility's protocol, staff are required to take baseline vital signs, monitor and record vital signs at specified intervals, complete neurological documentation, and wake the resident every two hours for 24 hours. The resident involved had a history of falls, cognitive impairment, and required supervision with toileting. After the unwitnessed fall, the Head Trauma Protocol form showed missing documentation for neurological and symptom checks at two time points during the night, as well as missing vital signs, neurological, and symptom documentation for a later shift. Interviews with staff revealed that the LPN responsible for the resident at the time of the fall could not recall why the checks were not documented, suggesting the resident may have been sleeping or that the documentation was overlooked. Another LPN who later cared for the resident was not informed of the need to continue the protocol and therefore did not complete the required checks or pass on this information to the next shift. The DON acknowledged missing the review of the Head Trauma Protocol form and stated that, despite the protocol's instructions, staff were not expected to wake a sleeping resident, though she also stated that staff should follow the protocol.