F0842

D

Failure to Complete and Accurately Document Neuro Checks After Unwitnessed Fall

Amesbury, Massachusetts Survey Completed on 02-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain a complete and accurate medical record for a resident following an unwitnessed fall. Facility policy on Charting and Documentation required that all services provided, observations, and any changes in a resident’s medical or mental condition be documented in the medical record. The Falls policy required that, after an unwitnessed fall, a Neurological Assessment be initiated and neurological signs be taken and documented for a minimum of 72 hours. The Neurological Assessment policy specified that the assessment included cognitive status, pupillary response, blood pressure, heart rate, temperature, respirations, and grip strength, with a defined frequency schedule over a 72-hour period.

Resident #1, admitted in July 2017 with diagnoses including dementia, chronic embolism and thrombosis of the lower extremities, diabetes, and a chronic ulcer of the right calf, was found sitting on the bathroom floor after an unwitnessed fall at 4:15 p.m. on 01/22/26. The facility’s Falls and Incident Assessment Tool documented that the resident’s neurological signs were within normal limits on initial assessment. However, review of the Neurological Assessment flow sheet for that date showed three neurological assessments documented without any times recorded; the space designated for time entries had been filled in with blood pressure readings instead. Only one additional neurological assessment was documented at 3:00 a.m. on 01/23/26, with no further post-fall neurological assessments found in the flow sheet or the medical record. During interview, the DON confirmed that nursing staff should have documented the resident’s neurological signs after the unwitnessed fall according to facility policy but had not done so.