Failure to Complete Neuro Checks After Unwitnessed Fall and Assess Resident Before Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to complete required neurological assessments after an unwitnessed fall and to document an assessment for a resident with a change in condition prior to hospital transfer. One resident with diagnoses including Diabetes Mellitus Type II, vascular dementia, and hypertension, and a BIMS score of five indicating cognitive impairment, experienced an unwitnessed fall on 08/01/25 and sustained a forehead hematoma. Review of the post-fall evaluation, nursing documentation, and post-fall monitoring records showed no documented neuro assessments following this unwitnessed fall, despite facility policy stating that neuro checks are to be initiated after any unwitnessed fall or when a resident hits their head. The DON confirmed that neuro assessments were expected in such situations and verified that none were documented for this resident after the fall. The deficiency also includes the facility’s failure to complete and document a nursing assessment when another resident with diverticulitis, hydronephrosis, hypertension, renal insufficiency, and an indwelling catheter experienced a change in condition and was transferred to the hospital. This resident’s care plan identified renal insufficiency and catheter-related risks, with interventions to monitor mental status, vital signs, and signs and symptoms of UTI, including altered mental status and behavior changes. The last documented nursing assessment showed the resident was alert and oriented with no acute complaints. On the date of transfer, a transfer form was completed, but there was no documented evidence in the medical record of a nursing assessment, recognition, or evaluation of a change in condition, and the transfer form lacked clinical data related to the change in condition. The DON confirmed that nurses are expected to complete and document an assessment for a significant change in condition and that no such documentation was available for this resident.
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