Ararat Nursing Facility

During a concurrent interview and record review on 8/28/2025 at 10:33 a.m. with RN 1, Resident 1's medical record was reviewed. RN 1 stated that for any unwitnessed fall, the nurses must assess the resident's neurological status for 72 hours after the fall occurs. RN 1 stated the resident's neurological status is to be checked every 15 minutes for 1 hour; followed by every 30 minutes for 1 hour; followed by every hour for 2 hours; and then, every 4 hours until 72 hours have been reached. RN 1 stated the neurological checks are documented on a paper form that is titled, Neurological Assessment Flowsheet. RN 1 reviewed Resident 1's Neurological Assessment Flowsheet, which indicated that Resident 1's neurological status was assessed on 8/25/2025 at 2:20 p.m. and 2:35 p.m. RN 1 stated when Resident 1 was re-admitted to the facility, the assessment of his neurological status resumed on 8/26/2025 at 1:05 a.m. but stopped after 4:05 a.m. RN 1 stated that Resident 1's neurological status was not assessed for 72 hours after he had an unwitnessed fall.

During a concurrent interview and record review on 8/29/2025 at 1:57 p.m. with the DON, Resident 1's Neurological Assessment Flowsheet that was initiated on 8/25/2025 was reviewed.

The DON stated Resident 1's neuro checks should have been done for 72 hours.

The DON stated neurological assessments are important for an unwitnessed fall because we don't know if they hit their head or not, and two days later we could have a bleed [in the brain].

The DON stated if something did happen, we can catch it right away by performing neurological checks.

During a review of the facility's policy and procedure (P&P) titled, Neurological Assessment, dated 8/1/2014, the P&P indicated the nurses will perform a neurological assessment.[f]ollowing an unwitnessed fall.for a combined total of 72 hours.

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