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A. Based on medical record review, staff interview and document review, it was determined that the facility failed to ensure that neurological checks are completed in accordance with facility policy.

Findings include:

Reference: Facility policy titled, "Incidents and Occurrences" states, "...F) Any incident of a head injury or suspected head injury must generate neurological checks. ..."

1. Review of Medical Record #1 on 12/9/2021 revealed the following:

a. A nursing note, dated 7/11/21 at 1630 (4:30 PM) stated, "patient was on the hallway, loud, talking, RN tried to redirect patient back to [his/her] room, but [he/she] refused redirection. Another patient ____[name of other patient] thought [he/she] was talking about [him/her] and punched [him/her] [sic] patient in the face. Patient complianed [sic] of pain, rated 10, and also complianed [sic] of seeing stars. MD was made aware, [him/her] po [by mouth] pain medication and ice pack was given, and the doctor ordered [him/her] to be sent out to the hospital for evaluation."

b. Upon interview with Staff #1, a neurological assessment was not initiated and completed.

c. There was no evidence in the medical record that Patient #1's vital signs were assessed.

d. A nursing note, dated 7/14/21 at 1440 (2:40 PM) stated, "...Patient fell from standing position onto left side. Seizure lasted for 35 seconds...MD ordered seizure precautions with vital sign and neuro [neurological] checks every 4 hours."

(i) There was no evidence that a neurological assessment was performed every 4 hours as ordered.

B. Based on medical record review, staff interview and document review, it was determined that the facility failed to ensure that a medication reconciliation was completed.

Findings include:

Reference: Facility policy titled, "Medication Reconciliation" states, "...Objective: To establish a standard as to avoid potential medication errors such as omissions, ... Medication Reconciliation is the process of creating the most accurate list possible, compared to the patient's medication list from the transfer facility, and/or discharge orders. Procedure: 1) The nurse will review the patient's prescribed medications as transmitted from a previous admission at Buttonwood Hospital, or referring facility. ..."

1. Review of documents from the sending facility indicated that Patient #1 was receiving Klonopin 1 mg (milligram) HS (hour of sleep) prior to admission.

a. There was no evidence that a medication reconciliation was completed in accordance with facility policy.

2. The above findings were confirmed with Staff #1.