Failure to Perform and Document Neuro Checks After Unwitnessed Falls
Penalty
Summary
The deficiency involves the facility’s failure to provide post-fall neurological assessments in accordance with its own Fall Evaluation and Prevention policy and acceptable standards of practice for three residents after unwitnessed falls. The policy, dated 8/2020, requires that following a fall, staff promptly evaluate the resident, obtain vital signs, perform a neurological evaluation, and, if the fall is unwitnessed or there is loss of consciousness, initiate neuro checks for at least 72 hours. The Interim DON and Previous Administrator stated they expected nurses to complete a head-to-toe assessment, obtain vital signs, start neuro checks for unwitnessed falls or head strikes, notify the physician, family/Resident Representative, and DON, and document post-fall monitoring once per shift for 72 hours. For one resident with diagnoses including hypertension, anxiety, restless leg syndrome, and spinal pain, an unwitnessed fall from bed occurred in the early morning hours. The incident report documented that the resident was found lying on their back on the floor with a skin tear to the left elbow and bruising on the left scapula, reported pain at a level seven out of ten, and received a skin assessment, vital signs, wound care, and PRN pain medication. The DON and physician were notified, but the family/emergency contact was not notified of the fall, and review of the medical record showed no documentation that neuro checks were completed following this unwitnessed fall. Another resident with moderate cognitive impairment and diagnoses including dementia, Parkinson’s disease, stroke, seizure, and repeated falls experienced an unwitnessed fall when they were found having slid from a wheelchair onto the floor in the hallway, resulting in a facial abrasion. Vital signs were obtained, hospice was contacted, and the resident was assisted to bed, with the DON and physician notified, but the family/responsible party was not notified. Record review showed no neuro checks were completed. A third resident with severe cognitive impairment and a history of prior falls, and diagnoses including seizure disorder, dementia, hypertension, sleep disorder, and osteoarthritis, had an unwitnessed fall while trying to get into bed. The incident report stated the resident did not hit their head, denied pain, and had no observed injuries, and noted that family and physician were aware with no new orders, but listed no people notified on the form. The medical record again showed no neuro checks completed for this unwitnessed fall.
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