Failure to Report Abnormal Neuro Findings and Monitor Post-Fall Residents
Penalty
Summary
The facility failed to provide necessary care and services to maintain the highest practicable well-being for two residents. For one resident with severe cognitive impairment, after returning from the hospital following a fall with a forehead laceration, neurological assessments documented fixed pupil reactions on multiple occasions. Despite these abnormal findings, there was no evidence that the physician was notified as required by facility policy. The Assistant Director of Nursing (ADON) confirmed that these findings were abnormal and should have been reported and documented. For another resident with intact cognition, following an unwitnessed fall, the medical record did not contain documentation of post-fall monitoring during the morning and night shifts. Facility policy requires 72-hour monitoring and documentation after a fall, including assessments and physician notification. The ADON verified that there was no documentation to show the resident was monitored as required during these shifts. Facility policies reviewed included requirements for neurological assessments, documentation after significant events, and post-fall management, all of which were not followed in these cases. The failures were confirmed through observation, interviews, and medical record review, and were acknowledged by facility leadership.