F0842

D

Incomplete Neuro Checks and IDT Documentation After Unwitnessed Falls

Coalinga, California Survey Completed on 02-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain complete and accurate medical records and to follow its own policies on falls, neuro checks, and documentation for two residents after unwitnessed falls. For the first resident, who had diagnoses including Type 2 diabetes mellitus, osteomyelitis of the right ankle and foot, COPD, and chronic heart failure, the facility’s records showed a moderate cognitive impairment with a BIMS score of 12 out of 15. On the date of the unwitnessed fall, progress notes documented that the resident was found sitting on the floor next to a wheelchair in the dining room after standing to get coffee, sliding to the floor, and landing on the bottom before falling sideways and hitting the right shoulder and head. An SBAR form documented that the primary care clinician was notified and recommended sending the resident to the ER for a head and right shoulder scan.

During review of this resident’s Neuro Checklist, which outlined required neuro check intervals (every 30 minutes x2, every 1 hour x3, every 2 hours x24 hours, every 4 hours x5, and every 8 hours for 24 hours), surveyors found that the initial vital signs, level of consciousness, pupil assessments, hand grips, and nurse initials were not completed for two subsequent days. The DON confirmed that the LVN assigned to the resident on those days should have completed the neuro checks to indicate that the resident’s neurological status was assessed. The DON stated that a delay in recognizing early neurological changes could delay the management of a serious neurological problem which could lead to serious negative outcomes such as permanent impaired cognition, speech, function, and mobility. The DON also stated that medical records should be complete and accurate to reflect the care provided.

For the second resident, who had diagnoses of Alzheimer’s disease and dementia and a BIMS score of 2 out of 15 indicating severe cognitive impairment, an SBAR documented that the primary care clinician was notified after an unwitnessed fall and that neuro checks were implemented, the resident was to be monitored for delayed injuries, and a one-time CT of the head was ordered. Progress notes for that date indicated that the resident had an unwitnessed fall in the bathroom after walking there and losing balance, with a small abrasion noted on the left big toe and an order placed for a CT of the head. However, review of the IDT Post Incident Meeting form for the following day showed that only the date and time of the IDT meeting were completed, and the remainder of the record was left blank. The DON stated that the IDT note should have been completed to indicate that the IDT met to discuss the fall, the cause of the fall, interventions to prevent recurrence, who was notified, and any new orders, and acknowledged that she did not complete the note. The Medical Records Director and Administrator both stated that residents’ medical records are required to be complete and accurate to reflect the care provided, and that partially completed or incomplete documentation indicates the service was not provided.

The facility’s policies and procedures titled “Falls - Clinical Protocol” and “Charting and Documentation” require assessment, cause identification, treatment/management, and monitoring and follow-up after falls, as well as documentation of all services provided and any changes in a resident’s medical or mental condition. The incomplete neuro checks for the first resident and the incomplete IDT documentation for the second resident demonstrate that the facility did not adhere to these policies. The DON specifically linked the failure to complete neuro checks to the potential for delayed recognition and management of serious neurological problems, and the Administrator stated that neuro checks were required to ensure the resident received the proper level of care and that the IDT note was required after an incident to ensure the resident’s care plan was appropriately aligned and that the IDT did not miss anything.