Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to complete required neurological checks following a head injury for one resident with Parkinson's disease and muscle weakness. After the resident experienced a fall, resulting in a laceration to the right ear and active bleeding while on a blood thinner, staff assisted the resident and transported them to the emergency department for evaluation and treatment. Despite a physician's order to initiate neurological checks for three days and monitor vital signs, the medical record lacked documentation of a post-fall assessment and neurological checks after the incident. The interim DON confirmed that these assessments were not completed as required by facility policy. Additionally, the facility did not obtain a physician's order for the application and care of a right-hand splint for another resident with hemiparesis following a cerebral infarction. The resident was observed wearing the splint, and therapy discharge recommendations included a splint and brace program. However, there was no documented physician order specifying the application or maintenance of the splint. Both the OTA and DON acknowledged the absence of a formal order and the importance of having one to ensure proper and consistent care, as outlined in facility policy.