LEESBURG, GA- LEE COUNTY HEALTH AND REHABILIATION

Based on record review, staff interview, and review of facility policy titled, ‘Skilled Nursing Services-Fall Management’, the facility failed to perform neurological checks for one resident (R#37) after a fall resulting infacial fracture.

Findings include:

Review of facility policy ‘Skilled Nursing Services-Fall Management’ last reviewed 12/20/2022 revealed: ‘Fall Event: When a fall occurs: Conduct a head-to-toe assessment to identify injuries or changes in condition.

Observe and interview the patient or witnesses to determine possible cause of the fall. Implement
intervention/s to prevent recurrence and maintain patient safety. Complete the Initial Event in the Electronic Health Record (EHR) to capture the investigation of the fall and assessment of the patient. Notify the attending physician and the patient’s family/responsible party of the fall and document notification. Implement any new orders received and update plan of care. Document the details of the occurrence in the patient’s medical record. Communicate the fall with other care providers as needed. Assess the patient at least every shift for 72 hours or until the patient is stable. Document the assessment findings in the medical record.

Review falls with the Interial Disciplinary Team (IDT) in the morning meeting to facilitate appropriate actions taken and documentation is accurate and complete (including Initial Event in EHR).’

Resident #37 was admitted to the facility 4/30/2021 with diagnoses including but not limited to contracture of the left knee, contracture of the right knee, dementia, hemiplegia and hemiparesis, and osteoarthritis. Review of the quarterly Minimum Data Set, dated dated dated [DATE] revealed a Brief Interview for Mental Status score of 4 out of 15, indicating severe cognitive decline. Section G-Functional Abilities revealed resident dependent on one-person physical assistance with activities of daily living.

Review of progress note dated 2/24/2023 revealed nurse was notified of resident having an unwitnessed fall.

Resident complained of pain and was noted to have a laceration to the nose. Further review of progress note dated 2/26/2023 revealed the results of facial x-ray showed acute mid nasal bone fracture. There is no evidence neurological checks were performed following unwitnessed fall.

During interview on 3/12/2023 at 9:35 a.m. with Director of Nursing revealed neurological checks should have been performed on resident following unwitnessed fall with injury to head. Confirmed neurological checks were not performed on resident following unwitnessed fall. Further revealed an intervention was not put into place until 3 days following resident fall. Stated resident should have had an intervention put in place and neurological checks done.