The resident had fallen at Robison Jewish Health Center on August 23 while attempting to transfer to the restroom without assistance. Staff administered pain medication for back pain but failed to follow the facility's own policy requiring 72 hours of neurological checks after any fall.
By the next afternoon, the resident's pain had intensified dramatically. A clinical progress note documented that the licensed practical nurse who responded to the fall "failed to complete neuro check assessments and monitor Resident 5 after her/his fall."
The facility's 2025 Resident Fall Procedure Guidance mandated that all residents who experienced falls be placed on neurological monitoring for 72 hours to detect changes in condition or altered cognitive status. Each check was supposed to be documented in a binder at the nurse's station.
No such documentation existed.
Federal inspectors reviewed clinical records for the resident on September 12 and found no evidence that any neurological assessments were completed after the August 23 fall. The resident had been rated as high fall risk and was recovering from joint replacement surgery at the time.
A second resident experienced similar lapses in monitoring after falling in the early morning hours of August 14. Staff discovered a bruise on the resident's left hand while assisting with toileting and connected it to a documented fall that had occurred at 3:33 AM.
The resident, who had been admitted in July with a right femur fracture and dementia, complained of significant pain in the left hip area after the fall. Clinical notes indicated the resident was "placed on neuro checks after the fall."
Those checks never happened.
Inspectors found no documented evidence that neurological assessments were completed for this resident either. The resident had also been rated as high fall risk and had limited mobility due to the femur fracture and dementia diagnosis.
When confronted with the missing documentation, a licensed practical nurse acknowledged the facility's neurological monitoring requirements but offered a stark explanation for the failures.
"Staff weren't always able to meet this requirement due to time being spent caring for other residents," the nurse told inspectors on September 8.
The admission revealed a staffing crisis that left nurses unable to complete basic safety protocols. Neurological monitoring after falls serves as a critical early warning system for traumatic brain injuries, which can be fatal in elderly residents if undetected.
Medical records staff confirmed on September 9 that no neurological check documentation existed for either resident. The administrator and director of nursing services acknowledged the following day that the licensed practical nurses responsible for both residents "did not follow post-fall procedures related to neuro checks."
Inspectors attempted to interview the two nurses who failed to complete the monitoring but were unable to reach them.
The violations occurred despite clear facility policies designed to protect residents from undiagnosed head injuries. The 72-hour monitoring window represents the critical period when symptoms of brain trauma typically emerge in elderly patients.
Both residents were considered high fall risk, making the neurological monitoring even more essential. The first resident was still recovering from major joint surgery, while the second had existing mobility limitations from a fractured femur and cognitive impairment from dementia.
The facility's own clinical staff documented the monitoring failures in progress notes, creating an internal record of the policy violations. One nurse specifically noted that required assessments were not completed, while another indicated a resident was placed on neurological checks that never occurred.
The gap between documented intentions and actual care delivery highlighted systemic problems with post-fall protocols. Staff acknowledged knowing the requirements but admitted they lacked time to fulfill them while caring for other residents.
Federal inspectors classified the violations as having potential for minimal harm, though the resident who developed excruciating pain the day after falling demonstrated the real-world consequences of missed monitoring. Without proper neurological assessments, staff had no systematic way to detect whether either resident had sustained brain injury from their falls.
The inspection occurred in response to complaints about care at the facility. Robison Jewish Health Center serves residents with complex medical needs, including those recovering from orthopedic surgeries and managing dementia-related mobility challenges.
Both residents who fell without receiving proper monitoring remained vulnerable to undetected brain injuries that could have proven life-threatening without prompt medical intervention.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Robison Jewish Health Center from 2025-09-10 including all violations, facility responses, and corrective action plans.