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Based on medical record review, interview, and policy and procedure review the facility failed to ensure patient rights were honored for care in a safe setting for 1 of 3 patients reviewed, Patient #1. The facility failed to follow current standards of practice when the patient experienced a witnessed fall with head and facial injury, there were no neurological assessments, and no immediate consultation with the physician to determine need for emergency medical care and transfer to another facility.

The hospital was not in compliance with the Condition of Participation for 42 CFR 482.13 Patient Rights, Requirements for Hospitals.

Refer to A144 - Patient Rights-Care in a Safe Setting.

Based on record review, interview, and policy and procedure review the facility failed to provide care in a safe setting and to ensure patients were free from medical neglect by failing to assess for neurological changes and immediately notify the physician when a patient experienced a fall resulting in head injury, Patient #1.

Findings include:

Review of the medical record for Patient #1 documented the patient was a 65-year-old admitted to the facility on 10/25/2022 with admission diagnoses to include psychotic disorder, hypothyroidism, Parkinson's disease, elevated blood pressure, migraines chronic pain and history of urinary tract infection.

Review of the facility Incident Report dated 10/26/2022 at 1830 (6:30 PM) reads, "Incident type: fall observed, Pre incident mental status: Confused, Site of Event: Hallway, Injury/incident caused by: self-inflicted, Treatment or intervention given: place on precautions, treatment refused, Notification of physician Notification time date: Blank, Physician response: No response required documented, Comments: The client was observed standing in the hallway where she suddenly fell striking her face on a metal doorframe, the client was evaluated by the RN [Registered Nurse] but refused treatment. The client is observed with contusion of the L [left] occipital area."

Review of the nursing progress notes for Patient #1 did not provide for documentation of the fall, there was no documentation of physician notification, and no documentation of a nursing assessment or neurological assessment of the patient after the fall.

Review of the Registered Mental Health Counselor intern [RMHCI's are able to practice on their own but are not yet licensed therapists] progress note dated 10/27/2022 at 4:21 PM reads, " .... She has a black eye and when asked she stated she fell and hit her head on the bed. When I met with her she was able to remain calm and understood that she needed to use different coping skills. Therapist and [Patient #1's name] discussed possible coping skills and identified the detrimental impact of aggressive behavior ...."

Review of the physician orders for Patient #1 dated 10/27/2022 authored by Advanced Practice Registered Nurse #2 reads, "Cold packs apply over left eye BID [twice a day] prn [as needed] for swelling."

Review of the Night shift nurses note for Patient #1 dated 10/30/2022 at 0250 (2:50 AM) reads, "pt [patient] has remained isolative to her room, lying in bed. Nurse approached pt who was calm and responsive but refused to take any medication. Periorbital bruising at left eye is severe but pt mostly denies pain, says it's a little sore up by her eyebrow."

During an interview on 7/10/2023 at 10:55 AM, the Risk Manger stated, "I did know that this patient fell. I cannot tell you why there is no documentation in the chart, no nurses notes. There should be. I do not see any documentation that the doctor was called. The incident report states she refused treatment. I don't know what that treatment was that was offered to the patient. I don't know why she was not sent out to [hospital's name] to be seen, there are no neurologic checks completed and there is no documentation that they were attempted and refused by the patient. It states she fell into a metal door frame and had an injury to her eye and head. We did know that there was an investigation for possible assault, but we did know that she had a fall, so there was not an assault. We did not investigate or review the record after the detective left here. We do have the ability to send people out to be medically cleared to an area hospital, [hospital's name]. There is no documentation in the record at all that we notified the doctor, that this was evaluated by any nurses, APRN's [Advanced Practice Registered Nurse] or doctors. She was seen by medical every other day and she was seen by psych. I can't tell you why there is no documentation related to her eye or head injury. There should be notes about the fall and what the nurses did, such as call the doctor and what they wanted done."

During an interview on 7/10/2023 at 3:30 PM Staff B, Registered Nurse (RN) stated, "I was not notified related to any fall that day for this patient. I did the review of the incident report the day after the incident. If there is a patient that has a fall with a head injury, we do neuro checks and notify the doctor. We will, with an observed fall with a head injury, send the patient out to the hospital for medical clearance. If a patient is voluntary, they can refuse to go to the hospital, but we need to document that in the chart. This patient was not here voluntarily, we should have sent her out. We should always document a fall, that we called the doctor or medical nurse practitioner and what they want to do, along with completing an incident report. I can't tell you why there is no documentation in the nurses' notes, there should be. Each day someone should have documented about the swelling and bruising of her eye, done a nursing assessment of that."

During a telephone interview on 7/11/2023 at 8:29 AM, APRN #1 stated, "I was not notified that the patient [Patient #1] fell the day it happened. I would assume that the doctor or nurse practitioner on call was. Any fall with a head injury should be sent out to get medically cleared. I expect that the staff will call me and notify me of any falls, assess the patient for any injuries and complete a full neuro [neurological] assessment with any head injury. I don't remember whether or not I saw a bruising of her eyes and I should have documented this in my notes. But I know I would have sent her out the day it happened if I was notified because this is standard practice, our elderly and even our younger patients cannot always tell us if they are having symptoms. I would have expected two days later that the patient had already been medically cleared for her head injury. At minimum, I expect the nurses to call a provider, and document any assessment for injuries. It is a standard for all head injuries to receive at minimum neuro checks to determine any changes that may not be able to be expressed by the patient. I only see patients when there is a need, or I am called or asked to see them. The units have a logbook that staff will write any concerns for us and why we need to see a patient."

During a telephone interview on 7/11/2023 at 8:49, AM Medical Doctor (MD) #1 stated, "I have no record of being called about this patient about her fall or any head or facial injury. With all head injuries we must send the patient out to obtain medical clearance and to rule out any subdural hematoma or bleeds. It is a standard procedure with all head injuries to obtain clearance with obvious facial injuries. Also, to start to do neuro checks every 15 minutes for at least one hour and we do them up to three days. Many psychiatric patients will not adequately express symptoms due to paranoia or delusions and we cannot take that responsibility that they don't have injuries further than our eyes can see. I would expect that all staff inform me that a patient has a fall, assess the patient for injuries, perform a neurologic assessment and document the findings in the chart. If a patient is on a Baker Act they cannot determine that they don't need to go to the hospital, or at least I can't let them. I would order the patient out and if they refuse, they refuse to 911/EMS [Emergency Medical Services] and that can be documented. We do have a responsibility to keep the patients safe and free from any medical problems while they are with us. The reason we send patients out with head injuries is we cannot always determine changes in a patient's neurological status if they will not allow neurological checks to be done. We need to get a CT [computerized tomography] scan to determine if any bleeds have occurred. I would say that it is dangerous for the patient not to be assessed for any possible brain injuries in the setting of a fall with injury to the periorbital area. They could have a facial fracture or a slow bleed. Subdurals can sometimes take weeks to present symptoms so that is why it is necessary to get the head CT."

During an interview on 7/11/2023 8:55 AM the Medical Director stated, "It is my expectation that all staff report any fall with or without injuries. If a patient has a head injury, it is protocol to notify the physician. Obtain orders for evaluation and monitoring and send the patient out for medical clearance. I am not sure what happened in this case, but if we do not document that we have assessed the patient, notified the physician, and attempted to complete a neurological assessment we were not providing quality care to the patient and practicing within industry standards. An unassessed head injury could have substantial risks to the patients' health and could have been detrimental to the patients' health and caused hospitalization and surgical interventions. It would be our responsibility to keep the patient safe and if they are refusing to let staff complete neuro checks we need them to go get a head CT. We should have sent the patient out for medical clearance."

During an interview on 7/11/2023 at 11:20 AM Staff C, RN stated, "I'm sorry I don't really remember much about her, but if I documented periorbital bruising is severe, it was severe. I would not need to notify the doctor if the fall was days old. The nurse on the day of the fall would need to document that information. I seem to remember that she had a fall a few days before I took care of her. We should absolutely call a doctor when a patient has a fall, and we would do neuro checks initially and call the doctor to continue them. It is policy to send patients out that have had a head injury with a fall. I did not look at the record to see if she had been sent out to the hospital. I guess I didn't think about it. The nurse that observed the fall would call the doctor and get orders to send a patient out to the hospital to make sure they didn't have any problems."

During an interview on 7/11/2023 at 11:43 APRN #2 stated, "I don't remember being told about any fall with that patient [Patient #1]. I would normally send a patient to the hospital if they fall with any type of head injury. If I was at the hospital the day that I gave the order for the ice packs, I would have written a progress note and evaluated the patient, if there is not a note than this was a telephone order. I would not have ordered her to go out if the fall happened the day prior to the call. I did not see her and that's really all I can recall. It is an expectation that staff call after a fall to obtain orders and document the fall and what our plan is. I would expect to have staff call me immediately. It is nursing 101 to complete a neurological assessment on any head injury patient, that should have been done and documented. We do have a unique population who will not always cooperate with our plans, so the best practice in light of that would be to send a patient out to the hospital for medical clearance and a head CT."

During an interview on 7/11/2023 at 12:04 PM the Director of Nursing (DON) stated, "It is my expectation staff should be documenting, following our fall policies and procedures, call the doctors to get orders on what to do. If head injuries occur, we should be completing neuro checks, calling physicians, and sending patients out to be cleared medically. This was not done. I am not sure why [Staff A's name] did not complete any documentation or document that he called the doctor and what the response was. We did not document or put in place anything related to this. There is no evidence that the prior DON looked into this either."

During a telephone interview on 7/11/2023 at 1:46 PM Staff D, RN stated, "I remember her vaguely, she was a fall that night, she fell before I got there that night. The day nurse took care of the patient. She did have a left eye that was swollen and bruised. I did not do neuro checks. She was extreme and was not allowing us to give her medications, and she needed an ETO [emergency treatment order] of medications because she couldn't be redirected and was getting physical with staff. I wouldn't call a doctor if another nurse had witnessed the incident, so I didn't mention this to the doctor that I called that night. I would have documented that. She seemed fine and was acting out. I did not notice anything at all. I really can't remember what the day shift nurse told me, it was months ago. But I guess I should have documented something about her eye and fall precautions."

During an interview on 7/12/2023 at 7:30 AM Staff A, RN, "What I remember is that the patient was calm and cooperative during the shift. She was confused with a lot of psychosis and was at her baseline. We received a lot of training, but I wasn't told a lot about the procedure. This is the first facility I have worked at. I worked home health until I started here. I started in September and didn't really know what to do when this happened. So, I went to see the patient, she didn't appear to have any other injuries. She told me that she hit her face on the doorway. I checked her for other injuries, she had a visible injury to her face and left eye. I asked if anything else hurt. She said no she didn't hurt anywhere else just her eye and head. I helped her to bed. I did not do any neurological checks on her, look at her pupils or anything else. I did not write a note or document anything. It was a chaotic day, a couple people needing help and ETO's. I did not call the doctor after she fell. I did not inform [MD's name]. I didn't know that I needed to send her out or anything else. I now know that I need to call the doctors or nurse practitioners and get orders for them. I would do things differently now."

During a telephone interview on 7/12/2023 at 8:10 AM, Staff D, RN stated, "I called the nurse practitioner I think around my shift change and told her that her eye was swollen [Patient #1] and asked her to get some ice for the eye. I did not tell her that the patient had a fall that I remember. I just told her that the patient had left eye swelling and bruising. The nurse practitioner, I don't know where she was, I did not ask her to evaluate the patient, this happened the day before and I would not have asked her because I really didn't think to ask her to evaluate the patient."

During a telephone interview on 7/12/2023 at 8:31 AM, APRN #2 stated, "I was asked by a nurse for an ice pack, sometimes staff will ask for orders. I really was not aware of the situation and would have seen the patient if I was in the building and placed the order and I did not see the patient, so I really cannot tell you what happened. I did not document on her, and I would have had I seen and evaluated her. If someone falls, I send them out to the hospital, and I absolutely would have sent her out if I had been told about her fall. I do not recall being told that she had a fall, and I did not ask. I would have seen her if staff had expressed the severity of the situation. I was not told she had a fall or that she had not been medically cleared. She should have went to the hospital on the day the event happened. I am asked for orders all the time and I will not see everyone I am asked for orders for because they don't need to be seen."

Review of the policy and procedure titled, "Neurological Checks "assessment of neurological status." Policy number 4936.0 reads, "Policy: The neurological status of patient will be assessed in cases of actual or suspected head trauma, or unexpected change in mental status. Procedure: 1. Neurological checks may be initiated as a nursing measure, or in conjunction with prescribed treatment as ordered by a physician. If initiated by a nurse, it is the responsibility to follow up with the physician for an order. 2. When initiated a nurse assesses the baseline functioning of the patient in relation to ability to arouse, gait, motor movement, verbal response, and pupil response. 3. Neurological checks will be initiated in cases of actual or suspected head trauma, or unexpected change in mental status: Symptoms may include but are not limited to: a. headache (increasing in severity), b. persistent nausea or vomiting, c. unusual drowsiness or inability to rouse, d. bleeding from either ear, double or blurred vision, e. garbled speech or difficulty talking, f. unusual behavior. Personality changes, h. seizure activity or i. unilateral weakness in arm or leg. 5. Neurological checks will be conducted by a RN according to physician orders. The RN will monitor for deviation from the baseline as established by the initial assessment. The patient overall neurological status. 6. Protocol: In the event that a patient falls and sustains a head injury, this protocol will outline the frequency of neurological assessments when ordered by the physician and be documented using the neurological assessment in EMR or on paper. A. Frequency i. every 15-minute times four (4), ii. Then neuro checks every 30 minutes times four (4), iii. Then Neurochecks every 1-hour times four (4), iv. Then neuro checks every 4 hours times four (4), v. Then Neurochecks every 8 hours times 6 for a total of 72 hours or as ordered by the physician, vi. Progress along this time schedule ONLY if signs are stable and within normal limits (WNL). 7. Notify physician immediately there are changes, or abnormal findings exist."

Review of the policy and procedure titled, "Patient Rights" Policy number 2045 effective date 1/2023 reads, "Policy: The facility supports the fundamental human dignity and the civil, constitutional, and statutory rights of each patient. The facility will provide services to any client that meets admission criteria regardless of sex, age, creed, sexual orientation, and national origin. The Vines Hospital will guard and preserve the individual rights of every client in order that the client can receive fair and equal treatment. Purpose: To provide a statement of specific rights for the patient and family, as well as for facility staff. To indicate the process whereby a patient can invoke protection under patient rights. The following rights are extended to each patient without reservation or limitations: B. Right to quality treatment. Each patient shall receive quality treatment suited to his or her needs, which shall be administered skillfully, safely, and humanely. Furthermore, each patient shall have the right to such treatment regardless of race, religion, sex, ethnicity, or handicap."

Review of the "The Vines Hospital Conditions of Admission" reads, "3. Medical emergencies: It is my understanding that during hospitalization at TVH medical emergencies may arise which would best be handled at a general facility. For this reason, I am authorizing a general care facility to treat the named patient for any condition that might occur."

Review of the policy and procedure titled, "Emergency Care" policy number: NUR4205.0 reads, "Purpose: To provide appropriate care based on the emergency and individual's needs. Policy: Persons who have been triaged as a priority 1-3 will be admitted to The Vines program or transferred to the appropriate facility based on the type of emergency."

Based on staff interview, medical record review and policy and procedure review the facility failed to identify and ensure its performance improvement activities were developed that focused on problem prone areas that affect health outcomes and patient safety when the facility failed to identify, investigate and develop an effective plan of correction when a patient experienced a fall with head injury. ( Patient #1)

Findings include:
Review of the medical record for Patient #1 documented that Patient #1 was a 65-year-old admitted to the facility on 10/25/2022 with admission diagnoses that includes psychotic disorder, hypothyroidism, Parkinsons disease, elevated blood pressure, migraines chronic pain and history of urinary tract infection.
Review of the facility Incident Report dated 10/26/2022 at 1830 ( 6:30 PM) reads, "Incident type: fall observed, Pre incident mental status: Confused ,Site of Event : hallway, Injury/incident caused by : self-inflicted, Treatment or intervention given: place on precautions, treatment refused, Notification of physician Notification time date : Blank, Physician response No response required documented ,Comments: The client was observed standing in the hallway where she suddenly fell striking her face on a metal doorframe, the client was evaluated by the RN ( registered Nurse) but refused treatment. The client is observed with contusion of the l ( left) ocipital( sp) area."

Review of the nursing progress notes for Patient #1 there was no documentation of the fall, there was no documentation of physician notification, and no documentation of nursing assessment or neurological assessment of the patient after the fall.
Review of the Clinical progress note dated 10/27/2022 at 4:21PM reads, " .... She has a black eye and when asked she stated she fell and hit her head on the bed. When I met with her she was able to remain calm and understood that she needed to use different coping skills. Therapist and [Patient #1's name]discussed possible coping skills and identified the detrimental impact of aggressive behavior ...."

Review of the physician orders for Patient #1 dated 10/27/2022 authored by Advanced practice Nurse Practitioner reads, "Cold packs apply over left eye BID ( twice a day) prn ( as needed) for swelling."

Review of the Night shift nurses note for Patient #1 dated 10/30/2022 at 0250 ( 2:50 AM) reads, " pt ( patient) has remained isolative to her room, lying in bed. Nurse approached pt who was calm and responsive but refused to take any meds. Periorbital bruising at left eye is severe but pt mostly denies pain, says it's a little sore up by her eyebrow. "

During an interview on 7/10/2023 at 10:55 AM the Risk Manger stated, " I did know that this patient fell, I cannot tell you why there is no documentation in the chart, no nurses notes. There should be. I do not see any documentation that the doctor was called. The incident report states she refused treatment. No I don't know what that treatment was that was offered to the patient. I don't know why she was not sent out to West Marion to be seen, there are no neurologic checks completed and there is no documentation that they were attempted and refused by the patient. It states she fell into a metal door frame and had an injury to her eye and head. We did know that there was an investigation for possible assault that was conducted in February and march of this year, but we did know that she fell, so there was not an assault. We did not investigate this after the detective left here. We do have a falls program, we do have the ability to send people out to be medically cleared to an area hospital, West Marion. There is no documentation in the record at all that we notified the doctor, that this was evaluated by any nurses, APRN's or doctors. She was seen by medical every other day and she was seen by psych. I can't tell you why there is no documentation. There should be notes about the fall and what the nurses did such as call the doctor and what they wanted done. We should have reviewed the documentation, we should have determined if there were areas of opportunity and provided training and education on the expectations when a patient has a head injury and we did not. I really can't tell you why we didn't. We were just cooperating with the detective about possible that may have happened. I do suppose we should have brought this to QAPI and developed a plan of correction and done a route cause analysis of the deficiencies in documentation , notification of the physician and nursing assessments completed after the patients fall."

During an interview on 7/11/2023 at 12:04 PM the Director of Nursing ( DON) stated, " It is my expectation that staff they should be documenting, following our fall policies and procedures, call the doctors to get orders on what to do. If head injuries occur we should be completing neuro checks, calling physicians, and sending patients out to be cleared medically. This was not done. I am not sure why [Staff's name]did not complete any documentation or document that he called the doctor and what the response was. We did not document or put in place anything related to this. There is no root cause analysis, no performance improvement plan and no staff education and training that was completed. There is no evidence that the prior DON looked into this either. "


During an interview conducted on 7/10/2023 at 1:50 PM the Chief executive Officer ( CEO) stated, " I was not here at the time of this incident, and I was unaware that there was any type of law enforcement investigation related to this patient. She did sustain a fall, there is no documentation in the medical record that she was sent out to be medically cleared or assessed by nurses or a doctor for any injuries. We should have done one of these. There was no investigation into what occurred, how the fall occurred. We did not evaluate the record or determine any of our concerns. This should have been investigated and we should have recognized the need for an RCA ( root cause analysis) and performance improvement plan. We should have done these things."

During an interview on 7/11/2023 8: 55 AM the Medical Director stated, "It is my expectation that all staff report any fall with or without injures. If a patient has a head injury it is protocol to notify the physician. Obtain orders for evaluation and monitoring and send the patient out for medical clearance. I am not sure what happened in this case, but if we do not document that we have assessed the patient, notified the physician and attempted to complete a neurological assessment we were not providing quality care to the patient and practicing within industry standards. An unassessed head injury could have substantial risks to the patients' health and could have been detrimental to the patients' health and caused hospitalization and surgical interventions. It would be our responsibility to keep the patient safe and if they are refusing to let staff complete neuro checks we need them to go get a head CT. We should have sent the patient out for medical clearance. I was unaware of this situation until today, we have not completed an investigation or met to discuss any concerns related to falls and head injuries."


Review of the policy and procedure titled, " Quality Assurance & Performance Improvement" reads, " 4. Purpose: The QAPI program is designed to provide a coordinated, objective and systematic approach to organization wide performance improvement activities. The program is based upon an integrated and collaborative approach to increase the probability of desired patient outcomes by assessing and improving those governance, managerial, clinical and support processes that most affect patient outcomes. The plan is used as a guide to design, measure, assess and improve organizational performance, identify, minimize and prevent organizational risks and ensure delivery of safe patient care.5. Goals and objectives: The call of the QAPI program is to assure continuous performance improvement in the delivery of quality health care that is efficient, cost effective and consistent with the facilities mission. The program promotes an organization wide commitment to continually meet and or exceed standards in the delivery of quality health care and services. The program emphasizes ongoing assessment of the dimensions of performance, including surveillance of health care delivery including the qualifications and performance of those managing and delivering the services, the outcomes of care and services delivered, the availability and utilization of support resources, facilities, staff, equipment and the environment to assure efficiency, cost effectiveness and accountability for both professional and paraprofessional staff. Objectives are: to provide an effective, planned, systematic mechanism to design, measure, assess and improve the performance of the facility. Achieve performance improvement goals and a systematic manner through collaboration with our physician and other stakeholders, to enhance maintain and continually improve the quality and safety of patient care through departments and service measures and assessment of patient care, resolution of problems and ongoing pursuit of opportunities to improve patient care. Provide a culture where are is delivered in a safe environment and quality care is measured, monitored and continuously improved period to facilitate a proactive approach toward continuous performance improvement and evaluate actions taken to assure that desired results are achieved and maintained. To promote communication and reporting of quality management activities by and between departments, administration, medical staff, governing body and others as deemed necessary period to maximize competent clinical performance by the medical staff and others through privileging, credentialing, orientation, training and continued education period to promote safety and prevent untoward occurrences through systematic monitoring of the treatment environment to reduce facility and medical liability. 8. Performance Improvement Committee: the performance improvement committee is the steering committee for the QAPI program. Core membership in the performance improvement committee includes the CEO, medical staff member, director of performance improvement, director of risk management, director of nursing, and director of clinical services social work. Other department leaders will attend based on reporting schedule. Ad hoc members can be included based on specific improvement opportunities. The director of performance improvement is the committee chairperson. The committee shall meet at least monthly. The committee records its activities and reports to the medical executive committee and the governing body at least quarterly. As the steering committee for the QAPI program the committee is responsible to oversee and accomplish the following: establish policy, create and ensure organizational preparedness for performance improvement activities by providing resources and training for program implementation. Design, maintain, support and document evidence of an ongoing program to systematically measure, assess and improve patient outcomes and organizational performance. Establishes the performance improvement methodology and prioritizes performance activities and hospital wide team activity. Receives reports of quality improvement activities from process improvement teams committees as assigned patient family satisfaction surveys and staff input regarding performance improvement activities. Establishes that comprehensive assessment and root cause analysis is initiated when data analysis indicates undesirable variations in performance. Assures that appropriate actions are implemented to effectively resolve identified problems or improve existing processes. Charters performance improvement teams at a minimum one per year to accomplish process, system and outcome improvements as indicated. Provides performance improvement teams with guidance and support to achieve goals. Reviews and approves team activities and proposed actions. Provides information, findings and ongoing communication to the governing body, medical staff, other organization committees as appropriate and staff at large. Evaluates the effectiveness of the performance improvement process through an annual evaluation of the plan with the medical executive committee."

Based on medical record review, interview, and policy and procedure review the hospital failed to ensure registered nurse supervision and evaluation of nursing care for 1 of 3 patients reviewed, Patient #1. The hospital failed to follow current standards of practice when the patient experienced a witnessed fall with head and facial injury, there were no neurological assessments, and no immediate consultation with the physician to determine need for emergency medical care and transfer to another facility.

The hospital was not in compliance with the Condition of Participation for 42 CFR 482.23 Nursing Services.

Refer to A395 - RN Supervision of Nursing Care

Based on record review, interview, and policy and procedure review the facility failed to ensure registered nurse supervision and evaluation of nursing care for 1 of 3 patients, Patient #1, by failing to assess for neurological changes and immediately notify the physician when a patient experienced a fall resulting in head injury.

Findings include:

Review of the medical record for Patient #1 documented the patient was a 65-year-old admitted to the facility on 10/25/2022 with admission diagnoses to include psychotic disorder, hypothyroidism, Parkinson's disease, elevated blood pressure, migraines chronic pain and history of urinary tract infection.

Review of the facility Incident Report dated 10/26/2022 at 1830 (6:30 PM) reads, "Incident type: fall observed, Pre incident mental status: Confused, Site of Event: Hallway, Injury/incident caused by: self-inflicted, Treatment or intervention given: place on precautions, treatment refused, Notification of physician Notification time date: Blank, Physician response: No response required documented, Comments: The client was observed standing in the hallway where she suddenly fell striking her face on a metal doorframe, the client was evaluated by the RN [Registered Nurse] but refused treatment. The client is observed with contusion of the L [left] occipital area."

Review of the nursing progress notes for Patient #1 did not provide for documentation of the fall, there was no documentation of physician notification, and no documentation of a nursing assessment or neurological assessment of the patient after the fall.

Review of the Registered Mental Health Counselor intern [RMHCI's are able to practice on their own but are not yet licensed therapists] progress note dated 10/27/2022 at 4:21 PM reads, " .... She has a black eye and when asked she stated she fell and hit her head on the bed. When I met with her she was able to remain calm and understood that she needed to use different coping skills. Therapist and [Patient #1's name] discussed possible coping skills and identified the detrimental impact of aggressive behavior ...."

Review of the physician orders for Patient #1 dated 10/27/2022 authored by Advanced Practice Registered Nurse #2 reads, "Cold packs apply over left eye BID [twice a day] prn [as needed] for swelling."

Review of the Night shift nurses note for Patient #1 dated 10/30/2022 at 0250 (2:50 AM) reads, "pt [patient] has remained isolative to her room, lying in bed. Nurse approached pt who was calm and responsive but refused to take any medication. Periorbital bruising at left eye is severe but pt mostly denies pain, says it's a little sore up by her eyebrow."

During an interview on 7/10/2023 at 10:55 AM, the Risk Manger stated, "I did know that this patient fell. I cannot tell you why there is no documentation in the chart, no nurses notes. There should be. I do not see any documentation that the doctor was called. The incident report states she refused treatment. I don't know what that treatment was that was offered to the patient. I don't know why she was not sent out to [hospital's name] to be seen, there are no neurologic checks completed and there is no documentation that they were attempted and refused by the patient. It states she fell into a metal door frame and had an injury to her eye and head. We did know that there was an investigation for possible assault, but we did know that she had a fall, so there was not an assault. We did not investigate or review the record after the detective left here. We do have the ability to send people out to be medically cleared to an area hospital, [hospital's name]. There is no documentation in the record at all that we notified the doctor, that this was evaluated by any nurses, APRN's [Advanced Practice Registered Nurse] or doctors. She was seen by medical every other day and she was seen by psych. I can't tell you why there is no documentation related to her eye or head injury. There should be notes about the fall and what the nurses did, such as call the doctor and what they wanted done."

During an interview on 7/10/2023 at 3:30 PM Staff B, Registered Nurse (RN) stated, "I was not notified related to any fall that day for this patient. I did the review of the incident report the day after the incident. If there is a patient that has a fall with a head injury, we do neuro checks and notify the doctor. We will, with an observed fall with a head injury, send the patient out to the hospital for medical clearance. If a patient is voluntary, they can refuse to go to the hospital, but we need to document that in the chart. This patient was not here voluntarily, we should have sent her out. We should always document a fall, that we called the doctor or medical nurse practitioner and what they want to do, along with completing an incident report. I can't tell you why there is no documentation in the nurses' notes, there should be. Each day someone should have documented about the swelling and bruising of her eye, done a nursing assessment of that."

During a telephone interview on 7/11/2023 at 8:29 AM, APRN #1 stated, "I was not notified that the patient [Patient #1] fell the day it happened. I would assume that the doctor or nurse practitioner on call was. Any fall with a head injury should be sent out to get medically cleared. I expect that the staff will call me and notify me of any falls, assess the patient for any injuries and complete a full neuro [neurological] assessment with any head injury. I don't remember whether or not I saw a bruising of her eyes and I should have documented this in my notes. But I know I would have sent her out the day it happened if I was notified because this is standard practice, our elderly and even our younger patients cannot always tell us if they are having symptoms. I would have expected two days later that the patient had already been medically cleared for her head injury. At minimum, I expect the nurses to call a provider, and document any assessment for injuries. It is a standard for all head injuries to receive at minimum neuro checks to determine any changes that may not be able to be expressed by the patient. I only see patients when there is a need, or I am called or asked to see them. The units have a logbook that staff will write any concerns for us and why we need to see a patient."

During a telephone interview on 7/11/2023 at 8:49, AM Medical Doctor (MD) #1 stated, "I have no record of being called about this patient about her fall or any head or facial injury. With all head injuries we must send the patient out to obtain medical clearance and to rule out any subdural hematoma or bleeds. It is a standard procedure with all head injuries to obtain clearance with obvious facial injuries. Also, to start to do neuro checks every 15 minutes for at least one hour and we do them up to three days. Many psychiatric patients will not adequately express symptoms due to paranoia or delusions and we cannot take that responsibility that they don't have injuries further than our eyes can see. I would expect that all staff inform me that a patient has a fall, assess the patient for injuries, perform a neurologic assessment and document the findings in the chart. If a patient is on a Baker Act they cannot determine that they don't need to go to the hospital, or at least I can't let them. I would order the patient out and if they refuse, they refuse to 911/EMS [Emergency Medical Services] and that can be documented. We do have a responsibility to keep the patients safe and free from any medical problems while they are with us. The reason we send patients out with head injuries is we cannot always determine changes in a patient's neurological status if they will not allow neurological checks to be done. We need to get a CT [computerized tomography] scan to determine if any bleeds have occurred. I would say that it is dangerous for the patient not to be assessed for any possible brain injuries in the setting of a fall with injury to the periorbital area. They could have a facial fracture or a slow bleed. Subdurals can sometimes take weeks to present symptoms so that is why it is necessary to get the head CT."

During an interview on 7/11/2023 8:55 AM the Medical Director stated, "It is my expectation that all staff report any fall with or without injuries. If a patient has a head injury, it is protocol to notify the physician. Obtain orders for evaluation and monitoring and send the patient out for medical clearance. I am not sure what happened in this case, but if we do not document that we have assessed the patient, notified the physician, and attempted to complete a neurological assessment, we were not providing quality care to the patient and practicing within industry standards. An unassessed head injury could have substantial risks to the patients' health and could have been detrimental to the patients' health and caused hospitalization and surgical interventions. It would be our responsibility to keep the patient safe and if they are refusing to let staff complete neuro checks we need them to go get a head CT. We should have sent the patient out for medical clearance."

During an interview on 7/11/2023 at 11:20 AM Staff C, RN stated, "I'm sorry I don't really remember much about her, but if I documented periorbital bruising is severe, it was severe. I would not need to notify the doctor if the fall was days old. The nurse on the day of the fall would need to document that information. I seem to remember that she had a fall a few days before I took care of her. We should absolutely call a doctor when a patient has a fall, and we would do neuro checks initially and call the doctor to continue them. It is policy to send patients out that have had a head injury with a fall. I did not look at the record to see if she had been sent out to the hospital. I guess I didn't think about it. The nurse that observed the fall would call the doctor and get orders to send a patient out to the hospital to make sure they didn't have any problems."

During an interview on 7/11/2023 at 11:43 APRN #2 stated, "I don't remember being told about any fall with that patient [Patient #1]. I would normally send a patient to the hospital if they fall with any type of head injury. If I was at the hospital the day that I gave the order for the ice packs, I would have written a progress note and evaluated the patient, if there is not a note than this was a telephone order. I would not have ordered her to go out if the fall happened the day prior to the call. I did not see her and that's really all I can recall. It is an expectation that staff call after a fall to obtain orders and document the fall and what our plan is. I would expect to have staff call me immediately. It is nursing 101 to complete a neurological assessment on any head injury patient, that should have been done and documented. We do have a unique population who will not always cooperate with our plans, so the best practice in light of that would be to send a patient out to the hospital for medical clearance and a head CT."

During an interview on 7/11/2023 at 12:04 PM the Director of Nursing (DON) stated, "It is my expectation staff should be documenting, following our fall policies and procedures, call the doctors to get orders on what to do. If head injuries occur, we should be completing neuro checks, calling physicians, and sending patients out to be cleared medically. This was not done. I am not sure why [Staff A's name] did not complete any documentation or document that he called the doctor and what the response was. We did not document or put in place anything related to this. There is no evidence that the prior DON looked into this either."

During a telephone interview on 7/11/2023 at 1:46 PM Staff D, RN stated, "I remember her vaguely, she was a fall that night, she fell before I got there that night. The day nurse took care of the patient. She did have a left eye that was swollen and bruised. I did not do neuro checks. She was extreme and was not allowing us to give her medications, and she needed an ETO [emergency treatment order] of medications because she couldn't be redirected and was getting physical with staff. I wouldn't call a doctor if another nurse had witnessed the incident, so I didn't mention this to the doctor that I called that night. I would have documented that. She seemed fine and was acting out. I did not notice anything at all. I really can't remember what the day shift nurse told me, it was months ago. But I guess I should have documented something about her eye and fall precautions."

During an interview on 7/12/2023 at 7:30 AM Staff A, RN, "What I remember is that the patient was calm and cooperative during the shift. She was confused with a lot of psychosis and was at her baseline. We received a lot of training, but I wasn't told a lot about the procedure. This is the first facility I have worked at. I worked home health until I started here. I started in September and didn't really know what to do when this happened. So, I went to see the patient, she didn't appear to have any other injuries. She told me that she hit her face on the doorway. I checked her for other injuries, she had a visible injury to her face and left eye. I asked if anything else hurt. She said no she didn't hurt anywhere else just her eye and head. I helped her to bed. I did not do any neurological checks on her, look at her pupils or anything else. I did not write a note or document anything. It was a chaotic day, a couple people needing help and ETO's. I did not call the doctor after she fell. I did not inform [MD's name]. I didn't know that I needed to send her out or anything else. I now know that I need to call the doctors or nurse practitioners and get orders for them. I would do things differently now."

During a telephone interview on 7/12/2023 at 8:10 AM, Staff D, RN stated, "I called the nurse practitioner I think around my shift change and told her that her eye was swollen [Patient #1] and asked her to get some ice for the eye. I did not tell her that the patient had a fall that I remember. I just told her that the patient had left eye swelling and bruising. The nurse practitioner, I don't know where she was, I did not ask her to evaluate the patient, this happened the day before and I would not have asked her because I really didn't think to ask her to evaluate the patient."

During a telephone interview on 7/12/2023 at 8:31 AM, APRN #2 stated, "I was asked by a nurse for an ice pack, sometimes staff will ask for orders. I really was not aware of the situation and would have seen the patient if I was in the building and placed the order and I did not see the patient, so I really cannot tell you what happened. I did not document on her, and I would have had I seen and evaluated her. If someone falls, I send them out to the hospital, and I absolutely would have sent her out if I had been told about her fall. I do not recall being told that she had a fall, and I did not ask. I would have seen her if staff had expressed the severity of the situation. I was not told she had a fall or that she had not been medically cleared. She should have went to the hospital on the day the event happened. I am asked for orders all the time and I will not see everyone I am asked for orders for because they don't need to be seen."

Review of the policy and procedure titled, "Neurological Checks "assessment of neurological status." Policy number 4936.0 reads, "Policy: The neurological status of patient will be assessed in cases of actual or suspected head trauma, or unexpected change in mental status. Procedure: 1. Neurological checks may be initiated as a nursing measure, or in conjunction with prescribed treatment as ordered by a physician. If initiated by a nurse, it is the responsibility to follow up with the physician for an order. 2. When initiated a nurse assesses the baseline functioning of the patient in relation to ability to arouse, gait, motor movement, verbal response, and pupil response. 3. Neurological checks will be initiated in cases of actual or suspected head trauma, or unexpected change in mental status: Symptoms may include but are not limited to: a. headache (increasing in severity), b. persistent nausea or vomiting, c. unusual drowsiness or inability to rouse, d. bleeding from either ear, double or blurred vision, e. garbled speech or difficulty talking, f. unusual behavior. Personality changes, h. seizure activity or i. unilateral weakness in arm or leg. 5. Neurological checks will be conducted by a RN according to physician orders. The RN will monitor for deviation from the baseline as established by the initial assessment. The patient overall neurological status. 6. Protocol: In the event that a patient falls and sustains a head injury, this protocol will outline the frequency of neurological assessments when ordered by the physician and be documented using the neurological assessment in EMR or on paper. A. Frequency i. every 15-minute times four (4), ii. Then neuro checks every 30 minutes times four (4), iii. Then Neurochecks every 1-hour times four (4), iv. Then neuro checks every 4 hours times four (4), v. Then Neurochecks every 8 hours times 6 for a total of 72 hours or as ordered by the physician, vi. Progress along this time schedule ONLY if signs are stable and within normal limits (WNL). 7. Notify physician immediately there are changes, or abnormal findings exist."

Review of the policy and procedure titled, "Charting Daily Nurses Progress Notes" policy number NUR4275.0 with an effective date of 8/2022 reads, "Policy: It is the policy of The Vines Hospital for nursing staff and therapist to document on patients progress notes. Purpose: Provide evidence of the daily individualized documentation of the continuity and quality care describing the patients progress, needs and assessments through the entire length of care in the inpatient acute care services."

Review of the policy and procedure titled, "Documentation Requirements" policy number 491 with an effective date of 1/2022 reads, "Policy: It is the policy of The Vines Hospital for clinical staff to document the patients progress and response to treatment goals and objectives on the patients progress notes. Purpose: To provide continuity and quality care by communication of patients progress and assessment through documentation. All Clinical Staff (all levels of care) 1. Will document facts and observations that documents the patients progress throughout the admission. Nursing Staff: Unit documentation critical incident documentation. 5. Will document narrative note of incident on same day."

Review of the policy and procedure titled, "Emergency Care" policy number: NUR4205.0 reads, "Purpose: To provide appropriate care based on the emergency and individual's needs. Policy: Persons who have been triaged as a priority 1-3 will be admitted to The Vines program or transferred to the appropriate facility based on the type of emergency."

Review of the "The Vines Hospital Conditions of Admission" reads, "3. Medical emergencies: It is my understanding that during hospitalization at TVH medical emergencies may arise which would best be handled at a general facility. For this reason, I am authorizing a general care facility to treat the named patient for any condition that might occur."

Based on record review and interview the facility failed to ensure patients' medical records contained complete information/documentation regarding assessments and evaluations for the availability of the physician and other care providers to use in making assessments of the patient's condition and interventions for 1 of 3 patients, Patient #1.

Findings include:

Review of the medical record for Patient #1 documented the patient was a 65-year-old admitted to the facility on 10/25/2022 with admission diagnoses to include psychotic disorder, hypothyroidism, Parkinson's disease, elevated blood pressure, migraines chronic pain and history of urinary tract infection.

Review of the facility Incident Report dated 10/26/2022 at 1830 (6:30 PM) reads, "Incident type: fall observed, Pre incident mental status: Confused, Site of Event: Hallway, Injury/incident caused by: self-inflicted, Treatment or intervention given: place on precautions, treatment refused, Notification of physician Notification time date: Blank, Physician response: No response required documented, Comments: The client was observed standing in the hallway Review of the nursing progress notes for Patient #1 did not provide for documentation of the fall, there was no documentation of physician notification, and no documentation of a nursing assessment or neurological assessment of the patient after the fall.

Review of the Registered Mental Health Counselor intern [RMHCI's are able to practice on their own but are not yet licensed therapists] progress note dated 10/27/2022 at 4:21 PM reads, " .... She has a black eye and when asked she stated she fell and hit her head on the bed. When I met with her she was able to remain calm and understood that she needed to use different coping skills. Therapist and [Patient #1's name] discussed possible coping skills and identified the detrimental impact of aggressive behavior ...."

Review of the physician orders for Patient #1 dated 10/27/2022 authored by Advanced Practice Registered Nurse #2 reads, "Cold packs apply over left eye BID [twice a day] prn [as needed] for swelling."

Review of the Night shift nurses note for Patient #1 dated 10/30/2022 at 0250 (2:50 AM) reads, "pt [patient] has remained isolative to her room, lying in bed. Nurse approached pt who was calm and responsive but refused to take any medication. Periorbital bruising at left eye is severe but pt mostly denies pain, says it's a little sore up by her eyebrow."

During an interview on 7/10/2023 at 10:55 AM, the Risk Manger stated, "I did know that this patient fell. I cannot tell you why there is no documentation in the chart, no nurses notes. There should be. I do not see any documentation that the doctor was called. The incident report states she refused treatment. I don't know what that treatment was that was offered to the patient. I don't know why she was not sent out to [hospital's name] to be seen, there are no neurologic checks completed and there is no documentation that they were attempted and refused by the patient. It states she fell into a metal door frame and had an injury to her eye and head. We did know that there was an investigation for possible assault, but we did know that she had a fall, so there was not an assault. We did not investigate or review the record after the detective left here. We do have the ability to send people out to be medically cleared to an area hospital, [hospital's name]. There is no documentation in the record at all that we notified the doctor, that this was evaluated by any nurses, APRN's [Advanced Practice Registered Nurse] or doctors. She was seen by medical every other day and she was seen by psych. I can't tell you why there is no documentation related to her eye or head injury. There should be notes about the fall and what the nurses did, such as call the doctor and what they wanted done."

During an interview on 7/10/2023 at 3:30 PM Staff B, Registered Nurse ( RN) stated, "If there is a patient that has a fall with a head injury, we do neuro checks and notify the doctor. We will, with an observed fall with a head injury, send the patient out to the hospital for medical clearance. If a patient is voluntary they can refuse to go to the hospital, but we need to document that in the chart. This patient was not here voluntarily, we should have sent her out. We should always document a fall, that we called the doctor or medical nurse practitioner and what they want to do, along with completing an incident report. I can't tell you why there is no documentation in the nurses notes, there should be. Each day someone should have documented about the swelling and bruising of her eye, done a nursing assessment of that."

During a telephone interview on 7/11/2023 at 8:29 AM, APRN #1 stated, "I was not notified that the patient [Patient #1] fell the day it happened. I would assume that the doctor or nurse practitioner on call was. Any fall with a head injury should be sent out to get medically cleared. I expect that the staff will call me and notify me of any falls, assess the patient for any injuries and complete a full neuro [neurological] assessment with any head injury. I don't remember whether or not I saw a bruising of her eyes and I should have documented this in my notes.

During a telephone interview on 7/11/2023 at 8:49, AM Medical Doctor (MD) #1 stated, "I have no record of being called about this patient about her fall or any head or facial injury. With all head injuries we must send the patient out to obtain medical clearance and to rule out any subdural hematoma or bleeds. It is a standard procedure with all head injuries to obtain clearance with obvious facial injuries. Also, to start to do neuro checks every 15 minutes for at least one hour and we do them up to three days. Many psychiatric patients will not adequately express symptoms due to paranoia or delusions and we cannot take that responsibility that they don't have injuries further than our eyes can see. I would expect that all staff inform me that a patient has a fall, assess the patient for injuries, perform a neurologic assessment and document the findings in the chart. If a patient is on a Baker Act they cannot determine that they don't need to go to the hospital, or at least I can't let them. I would order the patient out and if they refuse, they refuse to 911/EMS [Emergency Medical Services] and that can be documented. We do have a responsibility to keep the patients safe and free from any medical problems while they are with us. The reason we send patients out with head injuries is we cannot always determine changes in a patient's neurological status if they will not allow neurological checks to be done. We need to get a CT [computerized tomography] scan to determine if any bleeds have occurred. I would say that it is dangerous for the patient not to be assessed for any possible brain injuries in the setting of a fall with injury to the periorbital area. They could have a facial fracture or a slow bleed. Subdurals can sometimes take weeks to present symptoms so that is why it is necessary to get the head CT."

During an interview on 7/11/2023 8:55 AM the Medical Director stated, "It is my expectation that all staff report any fall with or without injuries. If a patient has a head injury, it is protocol to notify the physician. Obtain orders for evaluation and monitoring and send the patient out for medical clearance. I am not sure what happened in this case, but if we do not document that we have assessed the patient, notified the physician, and attempted to complete a neurological assessment we were not providing quality care to the patient and practicing within industry standards. An unassessed head injury could have substantial risks to the patients' health and could have been detrimental to the patients' health and caused hospitalization and surgical interventions. It would be our responsibility to keep the patient safe and if they are refusing to let staff complete neuro checks we need them to go get a head CT. We should have sent the patient out for medical clearance."

During an interview on 7/11/2023 at 12:04 PM the Director of Nursing (DON) stated, "It is my expectation staff should be documenting, following our fall policies and procedures, call the doctors to get orders on what to do. If head injuries occur, we should be completing neuro checks, calling physicians, and sending patients out to be cleared medically. This was not done. I am not sure why [Staff A's name] did not complete any documentation or document that he called the doctor and what the response was. We did not document or put in place anything related to this. There is no evidence that the prior DON looked into this either."

During a telephone interview on 7/11/2023 at 1:46 PM Staff D, RN stated, "I remember her vaguely, she was a fall that night, she fell before I got there that night. The day nurse took care of the patient. She did have a left eye that was swollen and bruised. I did not do neuro checks. She was extreme and was not allowing us to give her medications, and she needed an ETO [emergency treatment order] of medications because she couldn't be redirected and was getting physical with staff. I wouldn't call a doctor if another nurse had witnessed the incident, so I didn't mention this to the doctor that I called that night. I would have documented that. She seemed fine and was acting out. I did not notice anything at all. I really can't remember what the day shift nurse told me, it was months ago. But I guess I should have documented something about her eye and fall precautions.

During an interview on 7/12/2023 at 7:30 AM Staff A, RN, "What I remember is that the patient was calm and cooperative during the shift. She was confused with a lot of psychosis and was at her baseline. We received a lot of training, but I wasn't told a lot about the procedure. This is the first facility I have worked at. I worked home health until I started here. I started in September and didn't really know what to do when this happened. So, I went to see the patient, she didn't appear to have any other injuries. She told me that she hit her face on the doorway. I checked her for other injuries, she had a visible injury to her face and left eye. I asked if anything else hurt. She said no she didn't hurt anywhere else just her eye and head. I helped her to bed. I did not do any neurological checks on her, look at her pupils or anything else. I did not write a note or document anything. It was a chaotic day, a couple people needing help and ETO's. I did not call the doctor after she fell. I did not inform [MD's name]. I didn't know that I needed to send her out or anything else. I now know that I need to call the doctors or nurse practitioners and get orders for them. I would do things differently now."

Review of the policy and procedure titled, "Charting Daily Nurses Progress Notes" policy number NUR4275.0 with an effective date of 8/2022 reads, "Policy: It is the policy of The Vines Hospital for nursing staff and therapist to document on patients progress notes. Purpose: Provide evidence of the daily individualized documentation of the continuity and quality care describing the patients progress, needs and assessments through the entire length of care in the inpatient acute care services."

Review of the policy and procedure titled, "Documentation Requirements" policy number 491 with an effective date of 1/2022 reads, "Policy: It is the policy of The Vines Hospital for clinical staff to document the patients progress and response to treatment goals and objectives on the patients progress notes. Purpose: To provide continuity and quality care by communication of patients progress and assessment through documentation. All Clinical Staff (all levels of care) 1. Will document facts and observations that documents the patients progress throughout the admission. Nursing Staff: Unit documentation critical incident documentation. 5. Will document narrative note of incident on same day."

Review of the policy and procedure titled, "Neurological Checks "assessment of neurological status." Policy number 4936.0 reads, "Policy: The neurological status of patient will be assessed in cases of actual or suspected head trauma, or unexpected change in mental status. Procedure: 1. Neurological checks may be initiated as a nursing measure, or in conjunction with prescribed treatment as ordered by a physician. If initiated by a nurse, it is the responsibility to follow up with the physician for an order. 2. When initiated a nurse assesses the baseline functioning of the patient in relation to ability to arouse, gait, motor movement, verbal response, and pupil response. 3. Neurological checks will be initiated in cases of actual or suspected head trauma, or unexpected change in mental status: Symptoms may include but are not limited to: a. headache (increasing in severity), b. persistent nausea or vomiting, c. unusual drowsiness or inability to rouse, d. bleeding from either ear, double or blurred vision, e. garbled speech or difficulty talking, f. unusual behavior. Personality changes, h. seizure activity or i. unilateral weakness in arm or leg. 5. Neurological checks will be conducted by a RN according to physician orders. The RN will monitor for deviation from the baseline as established by the initial assessment. The patient overall neurological status. 6. Protocol: In the event that a patient falls and sustains a head injury, this protocol will outline the frequency of neurological assessments when ordered by the physician and be documented using the neurological assessment in EMR or on paper. A. Frequency i. every 15-minute times four (4), ii. Then neuro checks every 30 minutes times four (4), iii. Then Neurochecks every 1-hour times four (4), iv. Then neuro checks every 4 hours times four (4), v. Then Neurochecks every 8 hours times 6 for a total of 72 hours or as ordered by the physician, vi. Progress along this time schedule ONLY if signs are stable and within normal limits (WNL). 7. Notify physician immediately there are changes, or abnormal findings exist."