Failure to Perform Neurological Evaluation After Resident-to-Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to complete a neurological evaluation after a resident sustained a blow to the eye from another resident. A progress note dated 3/10/2026 at 10:19 PM documented that Resident 55 was sitting on their bed and reported that another resident hit him near his eye. On assessment, staff noted bruising to the left eye and a scratch under the right eye. A subsequent progress note dated 3/11/2026 at 5:18 PM documented that the IDT met to review the incident, confirming that Resident 55 had been in his room sitting on his bed when a nurse was called because another resident had made contact with his face. Ongoing 15-minute checks documented on 3/13/2026, 3/15/2026, 3/16/2026, 3/18/2026, and 3/19/2026 indicated that Resident 55 was resting in bed and that the bruising and swelling to the left eye continued to heal over time. However, in interviews, the Regional Vice President of Operations and the Regional Nurse Consultant both stated that the facility did not complete neurological checks or a neurological assessment following this incident. This was inconsistent with the facility’s current “Head Injury” policy, dated 1/2/2024, which required assessment following a known, suspected, or verbalized head injury, including a neurological evaluation for changes in physical function, behavior, cognition, level of consciousness, dizziness, nausea, irritability, slurred speech, or slow responses, and performance of neuro checks as indicated or specified by the physician.
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