F0689

D

Failure to Complete and Document Post-Fall Neuro Checks After Head Injury

Chesterfield, Virginia Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to conduct and document ongoing post-fall neurological assessments as required by policy for a resident who sustained a head injury. The resident was found on the floor during routine rounds, sitting on the side of the bed with both legs extended, and was noted to have a hematoma with a small laceration to the occipital area, with a small amount of blood on the floor and on the back of the head. The resident verbalized that they felt bad, that their head hurt, and also reported bilateral leg pain. Vital signs were obtained, the resident was assisted back to bed, the head wound was cleansed and gauze applied, and the nurse practitioner (NP) and responsible party were notified. The care plan response documented that neuro checks were initiated and that increased monitoring and safety checks were implemented.

Review of the neurological checklist showed that the first neuro check was documented at 4:10 AM with a reported pain score of 8/10, followed by three additional checks at 4:25 AM, 4:40 AM, and 4:55 AM. According to the facility’s neurological assessment policy, neuro checks were to be completed every 15 minutes for the first hour, every 30 minutes for the next two hours, and every hour for the next four hours. However, there was no documentation of any neuro checks or other neurological assessments between 4:55 AM and 7:30 AM, despite the requirement for continued monitoring. A nursing note entered at 7:08 AM stated that the resident was observed sitting upright on the bed, alert and in stable condition, with no acute distress noted and reporting soreness at the back of the head, but this note did not include a documented neurological assessment.

Interviews with staff confirmed the gap in monitoring and documentation. The NP stated that when a resident falls and hits or is suspected of hitting their head, neuro checks are ordered to monitor for changes from baseline and should be continued with notification of any changes. The unit manager (an LPN) and another LPN both described the facility’s neuro check protocol, including the required frequency and components such as vital signs, pupil reaction, grip, and range of motion, and acknowledged the importance of these checks. The LPN who assumed care at 7:00 AM reported that she was told to continue neuro checks and did so, but could not account for the lack of checks before her shift. The LPN on duty at the time of the fall confirmed that the resident fell, hit the head, and had bleeding with a bandage applied, and stated she did the neuro checks but suggested she may not have finished entering them into the record. The DON acknowledged there was a gap in evidence of monitoring and assessment from 4:55 AM until 7:30 AM. The facility’s written neurological assessment policy required completion and documentation of the neurological checklist at the specified intervals, which was not met in this case.