Failure to Follow Ordered Post-Fall Neurochecks and Vital Signs
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered post-fall neurological monitoring and vital signs for a resident following two unwitnessed falls with head impact. The resident had diagnoses including anemia, diabetes, and late-onset Alzheimer’s disease, with a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment, and was care planned as a fall risk related to impaired cognition, decreased safety awareness, Alzheimer’s, age-related cognitive decline, and sarcopenia. Facility documentation showed that on 12/27/25 the resident was found lying on the bedroom floor between the recliner and the bed after an unwitnessed fall, with moderate pain to the right side of the back and head, and later the same day had another unwitnessed fall with moderate head pain and an abrasion. A Third Eye Health note documented that the resident had two unwitnessed falls with head strike, reported back pain, and a 4 x 4 cm head laceration, and included specific provider orders for neurochecks with vital signs every 15 minutes for one hour, every 30 minutes for one hour, hourly for four hours, and then every four hours for 24 hours. Review of the Continuity of Care Document showed that neurochecks and vital signs were only completed at 2:41 p.m. and 8:48 p.m. on 12/27/25, and at 12:23 a.m., 8:13 a.m., and 3:53 p.m. on 12/28/25, which did not meet the ordered frequency. In interviews, the Director of Nursing confirmed that the facility did not complete the neurochecks and vital signs as ordered by the provider and acknowledged that the facility failed to provide appropriate care and treatment post fall for this resident.
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