The incident occurred on August 21, 2025, when a certified nursing assistant found Resident 1 on the floor during her afternoon shift. She immediately reported the fall to her supervisor at 5 p.m., according to federal inspection records.
Resident 1 was transferred to a general acute care hospital on August 22, 2025. No neurological check was performed between the time the fall was reported and the hospital transfer.
The facility's own job description for certified nursing assistants requires them to "Report all changes in the resident's condition to the Nurse Supervisor/Charge Nurse as soon as practicable" and "Report all accidents and incidents you observe on the shift they occur."
During interviews with federal inspectors on September 17, 2025, multiple staff members acknowledged the failure to assess Resident 1's neurological status violated proper care protocols.
LVN 3 told inspectors at 8:11 a.m. that a neurological check should be done following a resident's fall to monitor and assess for possible cognitive changes in the resident.
The Medical Records Supervisor confirmed during a 10:45 a.m. interview that Resident 1's neurological assessment was not initiated after the fall was reported. Records showed no neurological evaluation occurred prior to the hospital transfer.
The Assistant Director of Nursing reviewed Resident 1's neurological assessment records with inspectors at 11:18 a.m. She stated that Resident 1's neurological status was not assessed after learning he had fallen, but acknowledged it should have been done.
She explained that neurological checks were important because they identified abnormalities in the resident's cognitive function which could possibly lead to a stroke or a bleed in the brain. A stroke occurs when blood flow to the brain is interrupted.
The Director of Nursing told inspectors at 2:24 p.m. that a neurological assessment should be initiated after an unwitnessed fall or trauma to the head. She confirmed that one should have been initiated for Resident 1 after learning he had fallen.
The facility's own policy, titled "Neurological Assessment (Routine)" and dated January 2025, states that the purpose of the procedure is to provide guidelines for conducting a routine neurological assessment to evaluate residents for small changes over time that may be indicative of neurological injury.
Despite having this written policy and multiple staff members understanding the importance of neurological assessments after falls, the facility failed to conduct the evaluation for Resident 1.
Federal inspectors were unable to locate any facility policy indicating steps to take when a resident is found on the floor. The absence of such procedures may have contributed to the oversight in Resident 1's care.
The fall was classified as unwitnessed, meaning no staff member saw how or why Resident 1 ended up on the floor. This type of incident typically requires more thorough evaluation because the cause and potential injuries are unknown.
Neurological assessments are standard medical practice following falls, particularly unwitnessed ones, because they can detect subtle signs of brain injury that might not be immediately apparent. These evaluations check for changes in cognitive function, alertness, and neurological responses that could indicate serious complications.
The facility's failure to perform this basic safety measure meant that any potential neurological changes in Resident 1 went undetected during the critical hours between his fall and hospital transfer.
Staff interviews revealed that the nursing team understood the medical rationale for neurological assessments and had access to written policies requiring them. The breakdown occurred in the implementation of these protocols when they were most needed.
The inspection found that few residents were affected by this particular violation, and the level of harm was classified as minimal or potential for actual harm. However, the incident highlighted gaps between the facility's written procedures and actual practice during medical emergencies.
Resident 1's case demonstrates how administrative oversights can compromise resident safety even when staff members possess the knowledge and tools necessary to provide appropriate care. The consequences of missing neurological complications after falls can be severe, potentially delaying critical medical interventions.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Artesia Palms Care Center from 2025-11-25 including all violations, facility responses, and corrective action plans.