Failure to Complete and Document 72-Hour Neuro Checks After Unwitnessed Fall
Penalty
Summary
The facility failed to complete ordered 72-hour neurological checks following an unwitnessed fall for one resident. The resident was admitted with diagnoses including type 2 diabetes, abnormal posture, unspecified fall, and vascular dementia, and had moderately impaired cognition per the MDS. The resident required assistance with activities of daily living and was care planned as being at risk for falls with injury due to limited mobility, dementia, history of falls, unsteady gait, and weakness. On the date of the incident, a Change in Condition Evaluation documented that the resident experienced a fall and was found sitting on the floor. Following this unwitnessed fall, a 72-hour neuro check protocol was initiated, but the corresponding neuro check flowsheets showed that multiple required assessments were not completed. Specifically, the Infection Preventionist confirmed that several Q30-minute and Q1-hour neurological checks were missing and that the charge nurse responsible for the resident’s care was responsible for performing and documenting these assessments. Facility policies on neurological assessment required routine neuro exams to evaluate for small changes over time and mandated documentation of the date and time of the procedure, the person performing it, all assessment data, how the resident tolerated the procedure, any refusals and reasons, and the signature and title of the recorder. The facility’s charting and documentation policy further required that all services provided and any changes in the resident’s condition be documented in the medical record to facilitate communication among the interdisciplinary team, but this was not done for the missed neuro checks.
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