F0684

D

Failure to Document Neuro Checks After Unwitnessed Fall

Camden, Maine Survey Completed on 01-07-2026

Penalty

No penalty information released

Summary

The facility failed to ensure neurological checks were completed according to orders and facility practice for a resident reviewed for falls. The resident, who had dementia and a history of falls, experienced an unwitnessed fall in their room on 12/12/25 at 6:30 a.m., where they were found lying on their right side on the floor and reported having gotten up and slid on the floor. The incident report documented that the resident was assessed with no injuries and that initial neuro checks were completed and passed, but the medical record contained no evidence that ongoing neuro checks were performed after this unwitnessed fall. A subsequent, witnessed fall in the hallway on 12/16/25 was documented with no head impact, no injuries, normal ROM and vital signs, and transfer back to a chair near the nurses’ station for close monitoring. During an interview, the DON stated that neuro checks are done for every unwitnessed fall and provided a neuro check sheet dated 12/16/25, which she believed was intended for the 12/12/25 fall, but at the time of review there was no documentation of neurological checks in the medical record for the 12/12/25 unwitnessed fall, confirming the deficiency.