Failure to Perform Neuro Checks After Reported Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to complete neurological monitoring after a resident reported a head injury. The resident had diagnoses including traumatic subarachnoid hemorrhage without loss of consciousness (subsequent encounter), history of falling, syncope and collapse, asthma, hemiplegia/hemiparesis following cerebral infarction affecting the right dominant side, atherosclerotic heart disease, and type 2 diabetes mellitus. The resident was cognitively intact with a BIMS score of 14 and required one-person assistance with ADLs, was incontinent of bowel and bladder, and had right-sided weakness. On the early morning in question, the resident reported that a CNA hit or bumped her head on the bed/headboard during incontinence care and also alleged being punched in the face. Following the allegation, the CNA immediately reported the incident to the RN and the RN supervisor. The RN assessed the resident’s head and reported no bruising, swelling, bleeding, obvious injuries, or pain on palpation. The RN documented that the resident stated her head was hit on the bed and the right side of her face and that she was punched in the face, and the RN completed a risk assessment report, a physical injury incident report, and a pain assessment report. The DON later assessed the resident’s head and reported no bumps or discoloration. Multiple internal incident and risk management forms were completed, including a Post Altercation/Alleged Abuse assessment, an Accident/Incident Report, and Risk Management documentation. Despite the resident’s report of her head being hit and the facility’s own expectations and policy, no neurological assessment or ongoing neurological checks were performed or documented. The RN acknowledged that neurological monitoring should be conducted anytime there is a report of a head injury or suspected head injury, and the DON stated that any witnessed or unwitnessed head injury requires neurological status monitoring with neuro checks for 72 hours. The facility’s Neurocheck policy states that the nurse will inform the physician of the incident and follow physician orders, including a neurocheck on the resident. Review of the Post Altercation/Alleged Abuse assessment, Accident/Incident Report, Risk Management form, and progress notes from the date of the incident through several days afterward showed no neurological checks documented or performed, demonstrating the failure to provide appropriate treatment and care according to orders, resident preferences, and goals.
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