Failure to Perform Timely Neuro Checks and Assessment After Unwitnessed Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow its Neurological Evaluation policy after an unwitnessed fall for one resident. A behavior note documented that on 12/2/25 at 3:11 p.m., the charge nurse found the resident sitting naked on the floor next to the bed, described as playing a game with "my boys," very confused, hallucinating people and objects, and making unusual statements. The resident was dressed, placed in a Geri-chair, and positioned near the nursing station for observation. The behavior note did not document that a neurological assessment, vital signs, or a full assessment were completed at that time. A later nursing note, entered at 7:08 p.m. as a late entry, stated that CNAs had informed an LVN that the resident had been found on the floor earlier in the day, naked and hallucinating, and that the resident was dressed and assisted into a Geri-chair. The LVN documented that she then completed unwitnessed fall documentation, a skin assessment, and vital signs, and noted a new bruise on the resident’s right forearm. The Neuro/Vital Sign Flow Sheet showed that the first set of neuro checks was not completed until 6:30 p.m., approximately 3 hours and 15 minutes after the initial unwitnessed fall. In an interview, the LVN stated she was informed of the fall around 5:30 p.m. and that she was instructed to treat the fall as if it had just occurred. Additional documentation and interviews showed that the charge nurse did not initially report the incident as a fall, did not notify a supervisor, and did not complete a fall form at the time of the event because she did not believe the resident had actually fallen, based on the resident twice denying a fall. CNAs reported seeing the charge nurse picking the resident up from the floor and helping to put the resident back in bed, and reported that the charge nurse told them not to say anything and that it was the second time it had happened. The charge nurse confirmed in interview that she did not complete vital signs, neurological checks, or a full assessment at the time of the incident, and that her late-entry nursing note describing the fall was written a couple of days after the event. These actions and omissions did not comply with the facility’s Neurological Evaluation policy, which required immediate safety assessment, full assessment, vital signs, timely neuro checks, and documentation after any witnessed or unwitnessed fall where a head bump was suspected or the fall was unwitnessed.
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