F0684

D

Failure to Complete Required Neurological Checks After Resident Fall

Saxonburg, Pennsylvania Survey Completed on 02-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to complete required neurological assessments following a resident fall. Facility policy on Fall Prevention and Management dated 1/15/26 states that in the event of a fall, a licensed nurse will assess the resident, the physician/NP and responsible party will be notified, and appropriate documentation and interventions will be completed. The 72-Hour Neurological Assessment Sheet further specifies that for all falls, neurological checks are to be completed at defined intervals (initial assessment, then every 15 minutes x4, every 30 minutes x4, every hour x2, and once per shift for 72 hours), and that unwitnessed falls or falls in which the head is struck require neuro checks and physician notification for any change in condition.

The resident involved, identified as R1, had diagnoses including hypertension, seizure disorder, and hyponatremia, and experienced a fall on 1/18/26. A nursing progress note documented that at 4:15 p.m. the resident was found on the floor in his room, sitting on his buttocks, laughing, with the wheelchair at bedside and the bed on its side. The resident denied pain or discomfort, range of motion was within normal limits, no apparent injuries were noted, and vital signs were stable. The note stated that neuro checks were initiated per facility protocol. However, review of the 72-Hour Neurological Assessment Sheet dated 1/18/26 showed that only 8 neurological checks were completed out of 18 required opportunities. In an interview, the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to ensure the resident received the neurological assessments after the fall, resulting in the cited deficiency under 28 Pa. Code 201.14(a), 211.10(d), and 211.12(d)(1)(5).