Failure to Provide Appropriate Post-Fall Neurological Assessment and Emergency Response
Penalty
Summary
The facility failed to provide appropriate treatment and neurological assessments after a resident was found on the bathroom floor unresponsive with a head laceration following an unwitnessed fall. The resident had multiple diagnoses including dementia, COPD, type 2 diabetes with neuropathy, coronary artery disease, major depression with psychotic symptoms, anxiety, osteoarthritis, history of TIA, and hypertension, and had a care plan identifying fall risk with interventions requiring assessment for injury and completion of neuro checks after a fall with possible head injury or unwitnessed fall. On the morning in question, a CNA found the resident unresponsive on the bathroom floor; an LPN observed the resident diaphoretic, sweaty, clammy, with a head laceration and unable to perform range of motion due to lack of consciousness. Staff, including the unit manager, LPNs, and CNAs, lifted the unresponsive resident from the floor and placed him in bed, and EMS was not contacted at the time of discovery. The neurological observation form initiated at 8:00 A.M. documented only vital signs at multiple time points and did not include any documentation of pupillary responses or hand grasps, despite these being required elements on the form and part of a post-fall neurological assessment. The medical record contained no additional neurological assessment or further documentation beyond these vital signs. The LPN faxed the physician about the fall and awaited a response, notified the POA later that morning, and the DON was notified of the fall and change in condition; however, the resident remained unresponsive and never regained consciousness. The DON confirmed that the post-fall neurological assessment only contained vital signs and that staff did not contact EMS when the resident was first found unresponsive with an observed head injury, instead moving him back to bed. This sequence of actions and omissions formed the basis of the cited deficiency for failure to provide appropriate treatment and care according to orders, resident preferences, and goals.
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