Failure to Accurately Complete Required 72-Hour Neuro Checks After Unwitnessed Fall
Penalty
Summary
The facility failed to provide resident-centered care and services by not accurately completing a required 72-hour neurological assessment following an unwitnessed fall experienced by Resident 1. Resident 1 had been admitted with diagnoses including atrial fibrillation, muscle weakness, and a non-displaced fracture of the medial malleolus of the right tibia, and had severely impaired cognition per the most recent MDS. On the date of the incident, an SBAR Communication Form documented that Resident 1 had an unwitnessed fall resulting in a bump to the right forehead and severe forehead pain rated 8 out of 10. A 72-hour neuro check list was initiated at 8:30 p.m. in accordance with facility practice for unwitnessed falls; however, during review, the Assistant Director of Nursing (ADON) identified that the required assessment intervals were not accurately completed. Specifically, the every-30-minute neurological checks were not performed at the correct times, as they should have occurred at 9:15 p.m. and 9:45 p.m., but were instead documented at 9:00 p.m. and 9:30 p.m. Further review of the clinical record showed that Resident 1 was transferred to an acute care hospital later that evening and returned to the facility the following morning at 5:15 a.m. The ADON stated that, based on the documented return time, the 72-hour neurological checks should have resumed upon arrival and followed specific four-hour and subsequent interval times over the next several days, but the documentation did not reflect that these intervals were followed as required. The facility’s policies titled "Neurological Checks" and "Documentation Principles" required that neurological checks be conducted for 72 hours after a fall with head impact, using the appropriate form and timetable, and that the clinical record be current, accurate, timely, and consistent with good medical and professional practice. The inaccurate timing and incomplete documentation of the neuro checks for Resident 1, as identified by the ADON during record review, constituted the deficiency.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.