F0658

E

Failure to Perform Neuro Checks and Communicate with EMS After Falls and Change in Condition

Saint Peters, Missouri Survey Completed on 03-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its own neurological assessment policy and professional standards of practice after resident falls and changes in condition, and failure to provide pertinent information to EMS. For one resident with osteomyelitis, PVD, hypertension, and an active order for Eliquis, nursing notes documented that the resident rolled out of bed while reaching for a phone charger, was found on the floor with a gash to the right temple, swelling, and a reported headache, and that 911 was contacted. Vital signs were abnormal, and the dressing to the resident’s left foot was no longer intact. There was no documentation of a neurological assessment despite the head injury and the facility’s policy requiring neuro checks for unwitnessed falls and head injuries. The resident later returned from the hospital with a negative CT scan and sutures to the forehead, but no neuro checks were documented in the record.

The same resident reported lying on the floor for a long time after the fall, yelling for help and being unable to find the call light. The resident stated that when staff arrived, they said they could not get the resident off the floor because of the head injury and that they had to call 911, then left the room. The resident reported that no one applied anything to the head to stop the bleeding, and that the resident used a pair of pants to apply pressure. EMS personnel later confirmed finding the resident alone on the floor with pants on the forehead to control bleeding and no staff present in the room. EMS staff reported having to leave the room to locate a nurse, finding the RN at the nurses’ station, and that the RN came to the room only after EMS had the resident on the gurney, handed over paperwork, stated they were going to get an ice pack, and left without giving a report or providing care. The RN later acknowledged not starting neuro checks because the resident was going to the emergency room, not applying pressure to the laceration, not recalling if the resident was on blood thinners, and knowing that neuro checks should be done for unwitnessed falls.

Another resident with a history including fractured pelvis, toxic encephalopathy, acute respiratory failure, interstitial pulmonary disease, atrial fibrillation, anemia, and an order for apixaban had a care plan addressing anticoagulant therapy and monitoring for adverse reactions. A nurse practitioner documented bluish discoloration on the dorsum of both feet and ordered stat arterial and venous Doppler studies. The Doppler results showed acute DVT involving multiple veins in the left lower extremity, and the physician was notified. The medical record contained no further documentation of the resident’s condition, no additional physician orders related to the Doppler findings, and no documentation of transfer to the hospital, despite ambulance records indicating an emergent transfer for dyspnea. EMS documentation and family interviews indicated that when EMS arrived, no staff were in the room, the family provided the history including Doppler results and physician conversation, and staff only appeared about 20 minutes later as EMS was exiting with the resident. The nurse who entered the room did not know what was going on with the resident and told EMS that the resident’s shortness of breath was normal, and the corporate DON later stated that the nurse on duty should have documented and given report to EMS.

A third resident with stroke, dementia, severe cognitive impairment (BIMS of 4), dependence on staff for ADLs and mobility, and a history of multiple falls had a documented fall in which the resident rolled out of bed from the side opposite the fall mat and stated they hit their head. Nursing notes recorded that ROM and a neuro assessment were within normal limits for the resident and that vital signs were taken, with the resident transferred back to bed and the physician and responsible party notified. However, there was no documentation that neurological checks were completed per the facility’s neurological flow sheet protocol after this unwitnessed fall with reported head impact. The ADON confirmed that neurological flow sheets should be completed for every unwitnessed fall, that these are to be uploaded into the EMR, and that no such documentation existed for this resident. The ADON also confirmed that the fall for the first resident was not entered correctly into the EMR, so no post-fall assessment, neurological assessment, or care plan interventions were generated.