Failure to Complete Neurological Checks per Policy After Unwitnessed Falls
Penalty
Summary
The deficiency involves the facility’s failure to complete and document neurological assessments according to its own policy and procedure following unwitnessed falls for one resident. The facility’s Neurological Assessment policy, effective 5/19/22, requires neuro checks after head injuries or when indicated for a change in condition, including unwitnessed falls, with assessments of level of consciousness, speech, pupils, hand grasps, and vital signs. Unless otherwise ordered, the policy specifies a schedule of Q15 minutes × 1 hour, Q1 hour × 4 hours, then Q shift × 72 hours. The DON stated that the expectation is 4 fifteen‑minute checks, 4 one‑hour checks, and 4 eight‑hour checks, all documented in the electronic medical record. The resident involved had multiple diagnoses including wedge compression fracture of the second thoracic vertebra, fall history, pneumonia, type 2 DM, essential HTN, chronic heart failure, Alzheimer’s disease, and dementia, and had a BIMS score of 4 indicating severely impaired decision‑making. The resident experienced two unwitnessed falls on the same day, both documented as having no injuries, and the 24‑hour report indicated that neuro checks were initiated after each fall. For the first unwitnessed fall at 4:33 PM, documentation showed 4 fifteen‑minute neuro checks, 2 thirty‑minute checks, and 2 one‑hour checks, with no further checks completed per policy. For the second unwitnessed fall at 8:35 PM, documentation showed 4 fifteen‑minute neuro checks and 1 thirty‑minute check, with no additional checks completed per policy. No explanation was provided as to why the neurological checks were not completed in accordance with the facility’s policy and procedure.
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