Shelby Skilled Nursing And Rehabilitation

Review of the facility policy titled, Neurological Assessment, stated the purpose of the procedure was to provide guidelines for a neurological assessment: 1) upon physician order; 2) when following an unwitnessed fall; 3) subsequent to a fall with a suspected head injury; or 4) when indicated by resident condition.

The deficient practice was corrected on 10/20/25, when the facility implemented the following corrective actions: On 10/16/25, Unit Manager #145 assessed Resident #02 and was found to be absent from any adverse effects related to fall.

On 10/16/25, Unit Manager #145 notified Resident #02's responsible party of the concern. On 10/16/25, Unit Manager #145 notified the facility Nurse Practitioner of delay in the initiation of proper neurological checks following the fall on 10/16/25 and gave directions to initiate neurological checks at the beginning interval, per protocol, at the time of notification. On 10/16/25, Administrator suspended LPN #110 upon identification of delay in initiating appropriate neurological check post fall for Resident #02 on 10/16/25. On 10/17/25, LPN #110's employment was terminated. On 10/17/25, Director of Nursing (DON) completed medical record audit of current facility residents who had fallen in the past 60 days to ensure neurological checks were initiated promptly as per protocol and documentation was complete and accurate.

There were no variances as a result of the audit. On 10/17/25, DON or designee would audit all falls for head strike to ensure neurological checks were started as required five times per week for four weeks to ensure nurses are following post fall protocol. On 10/20/25, Unit Manager #145 educated the facility STNAs and nurses on fall management and neurological check policies. On 11/17/25, the results of audits will be reported to the Quality Assurance (QA) Committee.

This deficiency represents non-compliance investigated under Complaint Number 2624383.

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