Failure to Perform Neurological Checks After Unwitnessed Fall With Suspected Head Injury
Penalty
Summary
The facility failed to follow its neurological assessment policy and provide ordered care and services after an unwitnessed fall with suspected head injury for one of three reviewed residents. The facility’s policy, last reviewed on 2/20/25, required neurological checks following an unwitnessed fall or a fall with suspected head injury, with documentation of the date and time of each check, the person performing the assessment, and all assessment data. The facility’s neurological check flowsheet specified a standard frequency of every 15 minutes four times, every hour two times, and every four hours four times unless otherwise ordered by a physician. The resident involved was admitted on an unspecified date and had diagnoses including malnutrition, non-Alzheimer’s dementia, and adult failure to thrive, as documented on an MDS dated 12/9/25. On 12/12/25 at 11:20 a.m., the resident was found lying on the right side in front of a door with bleeding noted to the right frontal area at a site of a prior fall. The area was cleansed and bleeding stopped without difficulty, and the resident was assessed by a nurse practitioner; the family and hospice were notified, and the hospice physician ordered transfer to the hospital for further evaluation of a head injury. Review of the clinical record for that date showed no evidence that neurological checks were initiated or documented after this unwitnessed fall. In interviews, the DON and the Nursing Home Administrator confirmed that neurological checks were not performed and that the facility failed to provide the care and services needed for the resident to attain or maintain the highest practicable well-being.
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