Failure to Complete Neurological Assessments After Resident Fall with Head Injury
Penalty
Summary
Facility staff failed to appropriately assess and monitor a resident following a fall with injury. After an unwitnessed fall, the resident was found alert and responsive with a hematoma on her forehead. Initial interventions included checking the resident, helping her onto a chair, applying ice, and notifying the on-call physician and family. Although the facility's policy and staff interviews confirmed that neurological checks (neuro checks) should be performed at specific intervals following a fall with a head injury, the clinical record review revealed that the neurological assessment for this resident was grossly incomplete. Vital signs and other required neuro check components were either missing or dated incorrectly, indicating that the assessments were not performed as required. Staff interviews confirmed knowledge of the protocol for neuro checks after a fall with possible head injury, including the frequency and components of the assessment. The facility's policy also outlined the need for thorough and timely neurological assessments to detect early signs of brain injury. Despite this, documentation showed that the required neuro checks were not completed, and the resident was not adequately monitored for latent injuries following the fall.