F0689

D

Failure to Complete Post-Fall Neurological Assessments for Multiple Residents

Fort Wayne, Indiana Survey Completed on 03-31-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to complete neurological assessments after falls in accordance with its described practice for multiple residents. For unwitnessed falls, an LPN and the DON both stated that staff were to assess the resident for injuries, determine the cause of the fall, initiate neurological checks every 15 minutes for the first hour, then hourly for four hours, and then every shift for 72 hours, along with provider and family notification, skin and post-fall assessments, dehydration assessment, and documentation. Record review for a resident with epilepsy, dementia, and diabetes showed missing neurological assessments following an unwitnessed fall on specific dates and times, including incomplete checks on the night and subsequent shifts.

Another resident, also with epilepsy, dementia, and diabetes and care planned as being at risk for falls with an intervention to follow the facility fall protocol, had multiple missing neurological assessments after falls. These included missing second-shift neuros on several consecutive days, missing neuros at multiple specified times on another date, and absent first- and second-shift neuros on a subsequent date, as well as missing neuros at designated early-morning times and no documented every-shift neuros for 72 hours on three days. A third resident with dementia, abnormal posture, and diabetes had no neurological assessments located by the DON for multiple falls over several days, and neuros were also missing for three days following a fall later in the year. The facility’s written Falls Clinical Protocol required assessment and documentation of neurological status and related factors after falls but did not specify the frequency of neurological assessments.