Failure to Complete and Document Neuro-Checks and Full-Body Skin Assessments After Multiple Unwitnessed Falls
Penalty
Summary
The deficiency involves the facility’s failure to complete and document neurological assessments and full-body skin assessments as ordered and care planned for a resident with multiple risk factors. The resident had intact cognition but significant medical conditions including anxiety, aphasia, diabetes, heart failure, hemiplegia, and a history of stroke, and was dependent on staff for all care and transfers. The resident had two or more falls since the prior MDS assessment, was at risk for pressure injuries, and had a diabetic foot wound and an open foot lesion. The care plan included neuro-checks per facility policy for falls and skin inspections due to self-care deficits. Facility incident reports showed 21 unwitnessed falls over several months, but neuro-checks were initiated and documented for only 13 of these falls, and 8 of those 13 neuro-check forms were incomplete, missing one or more of the scheduled assessments required by the facility’s Falls Management System policy and Neurological Assessment form. The facility also failed to consistently complete and document full-body skin assessments for this resident. Weekly full-body skin reviews were documented from late July through early November, but no full-body skin assessments, either electronic or paper, were identified from mid-November through the end of December. During this period, only focused diabetic/neuropathic foot evaluations were documented, which did not address the rest of the body. Progress notes identified a bruise near the left upper eye area and, later, a bruise and skin tear to the right elbow following a fall, as well as cuts on the resident’s hand from fingernails, with treatment orders initiated. However, there was no further documentation in progress notes or skin assessments tracking these injuries. Staff interviews confirmed that neuro-checks for unwitnessed falls were expected to be completed and documented, and that full-body skin assessments were expected on bath days and during weekly skin assessments, but acknowledged that full-body checks were not consistently performed and documented for this resident.
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