Failure to Perform and Document Neurological Checks After Unwitnessed Fall
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan following an unwitnessed fall. The resident, who had a history of dementia, cognitive decline, and previous falls, experienced an unwitnessed fall resulting in a laceration and hematoma to the head. According to the facility's fall management and neurological check policies, neurological checks were required to be performed and documented for 72 hours following such an incident. Despite these requirements, there was no documentation of initial or ongoing neurological checks for the resident after the fall. Interviews with nursing staff and the DON revealed that while some neurological assessments may have been performed, they were not documented as required by policy. Staff indicated that neurological checks were not completed or documented because the resident was sent to the hospital, and there was confusion regarding whether checks should continue upon the resident's return without a physician's order. The facility's own policies, however, specified that neurological checks should be performed and documented after unwitnessed falls, regardless of hospital transfer, unless otherwise directed by a physician. Record reviews confirmed the absence of neurological check documentation in both the neurological checks binder and the resident's progress notes. Multiple staff interviews acknowledged the lapse in following policy, and the DON confirmed that staff did not adhere to the facility's procedures for neurological monitoring after the fall. The failure to perform and document neurological checks as required constituted a deficiency in providing care according to professional standards and the resident's care plan.