Failure to Complete Post-Fall Neuro Checks and Implement Care-Planned Fall Interventions
Penalty
Summary
The deficiency involves the facility’s failure to complete ordered post-fall neurological assessments and to implement care-planned fall interventions for a resident at risk for falls. The resident had multiple diagnoses including neuroleptic-induced Parkinsonism, hemiplegia and hemiparesis after cerebral infarction, bipolar disorder, anxiety disorder, repeated falls, adrenocortical insufficiency, and chronic kidney disease stage 3B, and had intact cognition with a BIMS score of 14. The care plan identified the resident as at risk for falls related to altered mental status, use of antidepressant and antipsychotic medications, history of falls, unsteady gait, poor safety awareness, and noncompliance, with interventions such as assisting with all transfers and mobility, arranging the room for ease of transfers, and placing non-skid strips between the bed and the bedside commode. After the resident was found on the floor on 11/23/25, staff assisted the resident to a chair, educated the resident on call light use and not ambulating without assistance, and initiated neurological checks per protocol. However, review of the neurological check documentation showed that the ordered schedule of every 15 minutes for one hour, every 30 minutes for two hours, every hour for two hours, and then every shift for 72 hours was not followed. On 11/23/25, checks were not completed every 15 minutes as required and were only documented at 1:30 p.m., 1:45 p.m., and 2:10 p.m., and subsequent checks were not completed every 30 minutes, but instead at 3:00 p.m., 5:00 p.m., 9:00 p.m., and 11:00 p.m. The DON confirmed that staff did not follow the neurological check protocol. In addition, observation of the resident’s room revealed there were no skid strips next to the bed leading to the bedside commode, despite the care plan intervention for non-skid strips between the bed and commode. The resident reported that skid strips helped prevent slipping during transfers and that none had been in place since a bedside mat was removed on 01/30/25. The Director of Rehabilitation stated that skid strips should be in front of the bedside commode and directly next to the bed, and the DON verified that no skid strips were present, indicating that the care-planned fall prevention intervention was not implemented.
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