The resident had fallen and sustained a bump and bruising to the back of the head. Federal inspectors found that required neurological checks were documented as completed but never actually performed.
Licensed Practical Nurse #261 admitted during a September interview that she did not complete the neurological assessments scheduled for 1:25 P.M. and 1:55 P.M. She also failed to assess the resident's pupils, consciousness, speech, and responsiveness at 2:25 P.M. Instead, she documented on the assessment form that she was distributing medications elsewhere in the facility.
The missed assessments became more concerning when nurses discovered they could not arouse the resident during the 2:25 P.M. vital signs check. The patient remained unresponsive, yet no neurological evaluation was performed to determine the cause.
The resident's medical history heightened the risks. Quarterly assessment records showed the patient had severe cognitive impairment and was completely dependent on staff for care. More critically, the resident was prescribed Eliquis, a blood-thinning medication that increases the risk of serious bleeding from head injuries.
The facility's Director of Nursing acknowledged during an interview that the combination was "concerning." She confirmed that vital signs were completed at 2:25 P.M., but the resident could not be aroused for the required neurological assessment.
Communication failures compounded the medical oversights. The resident's family and the Medical Assistant were not notified about the fall with injury until later in the day, according to the Director of Nursing. The MA who should have been contacted about the incident no longer worked at the facility and was unavailable for questioning about when they were notified or whether they knew the resident was taking blood thinners.
The inspection revealed that two nurses were working during the shift when the neurological assessments should have been completed. The Director of Nursing provided scheduling records and clock-in times to verify adequate staffing was present.
Despite having staff available, the required brain injury protocols were abandoned. Neurological assessments after head trauma are designed to detect signs of bleeding or swelling in the brain, particularly dangerous for patients on anticoagulant medications like Eliquis.
The Medical Assistant had been notified at 7:12 P.M. that the resident had fallen with head injuries, and that neurological checks were "at baseline." However, the Director of Nursing later confirmed that these baseline neurological checks had never actually been performed.
LPN #261's explanation for missing the assessments centered on her medication distribution duties on a different hallway. The nurse verified she was working during the day of the incident but chose to document her absence from the required assessments rather than complete them or ensure another nurse performed the evaluations.
The case emerged from two complaint investigations numbered 1314302 and 1314300. Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents.
The facility's failure to complete neurological assessments after a head injury represents a breakdown in basic safety protocols for vulnerable residents. When patients on blood thinners suffer head trauma, prompt and repeated neurological evaluations can mean the difference between catching a life-threatening brain bleed early or missing it entirely.
The resident who couldn't be awakened for vital signs never received the brain injury monitoring that medical standards require. Their family learned about the fall hours after it happened, long after the critical window for detecting complications had passed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Signature Healthcare of Galion from 2025-09-16 including all violations, facility responses, and corrective action plans.
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