F0684

D

Failure to Complete Post-Fall Neuro Checks and Ongoing Wound Assessments

Tabor, Iowa Survey Completed on 03-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards and physician orders for two residents, specifically related to post-fall neurological assessments and wound assessments. For one resident with a history of stroke, psychiatric diagnoses, and multiple prior falls and fractures, the clinical record documented numerous falls, both witnessed and unwitnessed, over several months. The resident’s care plan identified a high risk for falls and included multiple fall-prevention interventions. Progress notes and facility fall documents listed several unwitnessed falls, including events where the resident lowered herself to the floor, fell from a recliner, slid from a wheelchair, or slipped while reaching for a call light. Despite these events, the neurological checklist and assessment records showed that neuro checks were only completed for some of the falls.

The same resident’s medical record lacked neurological assessments for several unwitnessed falls on specific dates, even though the facility’s own staff, including the MDS Coordinator/LPN and the DON, stated that their expectation was that neurological assessments be completed after unwitnessed falls. The record showed neuro assessments on certain dates, but for other documented unwitnessed falls, only 15‑minute checks or no neuro assessments at all were recorded. Physician notifications were documented for some falls, and an emergency room report following one fall indicated no acute injuries, but the absence of consistent neurological assessments after unwitnessed falls represented a failure to follow the facility’s stated expectations and professional standards for post-fall evaluation.

The second resident had chronic venous hypertension with ulcer and inflammation of the right lower extremity and a history of significant leg trauma with hardware in place. Facility documents showed that the resident had been referred to a wound care clinic, with physician orders noting that the right lower extremity wound probed down to hardware and that there was a chronic implant-related infection. Observations revealed multiple small scabbed areas on the inner right lower extremity. Review of the EHR showed that, over the prior year, there were no consistent wound assessments with measurements or detailed descriptions in the wound assessment section, and only a few progress notes contained wound measurements on scattered dates. Other progress notes documented only monthly skin assessments without wound descriptions or measurements.

Nursing staff interviews confirmed inconsistent understanding and implementation of wound assessment practices. One RN who frequently performed the resident’s wound care stated she did not know when skin assessments were supposed to be completed and reported that the wound had not worsened, indicating she would have notified the DON and physician if it had. Another LPN stated that skin assessments were supposed to be completed weekly with measurements and descriptions and reported entering measurements during a treatment. The DON acknowledged that there were not as many wound assessments in the progress notes as expected and that assessments were not completed appropriately by nursing staff. The PCP reported he had not recently examined the wound and had no notes from the wound clinic, and stated he would expect the facility to notify the wound clinic of any changes. Review of facility policies on documentation and wound assessments showed requirements for detailed wound descriptions, weekly measurements, and thorough documentation of treatment and wound appearance, which were not consistently followed for this resident’s chronic wound.

Facility policies titled “Protocol for Documentation” and “Protocol for Wound Assessments” required that wound care notes include treatment provided, detailed appearance of the wound, new concerns, physician notification for ongoing treatment, EHR updates to reflect current treatment, and weekly measurements documented in the EHR. The review of the resident’s records demonstrated that these requirements were not met, as there were gaps in wound assessments, lack of consistent measurements, and insufficient descriptive documentation over many months. Together with the missing neurological assessments after multiple unwitnessed falls for the other resident, these findings show that the facility failed to provide needed services and assessments in accordance with professional standards and its own policies for both post-fall care and wound management.