Failure to Document Neurological Monitoring After Unwitnessed Fall
Penalty
Summary
Facility staff failed to follow professional standards of practice for monitoring a resident after an unwitnessed fall. Specifically, for one resident who was assessed as being at moderate risk for falls and was taking anticoagulant medication, there was no documented evidence of neurological checks being completed after the resident was found on the floor. The facility's own policy required observation and documentation of neuro checks for approximately 48 hours following an unwitnessed fall, but the clinical record did not contain this documentation. The resident's progress notes indicated that after being found on the floor, an initial assessment was performed, and the responsible party and nurse practitioner were notified. The notes referenced that a neurological assessment was in place, but there was no further evidence of ongoing neuro checks in the medical record between the time of the fall and the resident's departure for a medical appointment the following day. Interviews with staff confirmed that neuro checks should have been performed and documented, but no such documentation could be produced. The facility's fall investigation also failed to provide evidence of completed neuro checks, despite indicating that they had been initiated. The care plan for the resident identified a risk for falls due to multiple medical conditions, including impaired mobility, respiratory failure, and infection. Administrative and clinical staff were unable to provide any additional documentation of neuro checks when asked, confirming the deficiency in following professional standards for post-fall monitoring.