Staff at Chapters Living of Council Bluffs discovered the injury on Resident 30's right forehead at 7:30 AM on January 4. The facility's director of nursing later acknowledged that staff should have immediately contacted the physician, notified the family, and started neurological assessments. None of this happened until evening.
The resident had been combative the night before the injury was discovered. According to the director of nursing's investigation, Resident 30 had kicked one employee in the groin and hit another employee during the evening shift on January 3.
When staff found the red area on her forehead the next morning, they failed to follow basic protocols for head injuries. The director of nursing told inspectors she would have expected immediate notification at 7:30 AM when the injury was first noticed.
Medical records show the first neurological assessment wasn't started until 6:00 PM that day, nearly 11 hours after the injury was discovered. The physician wasn't notified until 7:27 PM, when staff faxed a report describing a 3 cm by 2.5 cm hematoma of unknown origin.
By evening, the injury had worsened significantly. What started as a red area in the morning had developed into a raised hematoma by the time the resident's daughter visited that afternoon. The daughter asked about the area on her mother's forehead, apparently having forgotten an earlier notification about the injury.
The facility's nurse practitioner, contacted by inspectors on January 13, said she expected staff to call immediately with any head injuries and start neurological assessments right away. She confirmed receiving notification on January 4 about the forehead injury, but said staff reported the resident had given conflicting stories about how it happened.
The director of nursing's investigation revealed additional protocol failures. Staff had initially told her that Resident 30 wasn't on blood thinners, which influenced the decision not to start immediate neurological monitoring. However, medical records from that evening show the resident's propranolol medication was held due to low blood pressure and a slow pulse rate.
During her investigation, the director of nursing interviewed staff about the incident. They reported that Resident 30 had showered the day before but hadn't fallen. The resident herself stated she hit her head on the bedside table on the morning of January 4.
The director of nursing concluded the injury likely occurred during the previous evening's aggressive episode, despite the resident's account of hitting the bedside table. She told inspectors that Resident 30's cognitive abilities were sufficient to provide a credible explanation of the incident.
Staff documented the injury in a skilled nursing note at 7:49 PM, more than 12 hours after discovery. The note indicated the on-call provider, director of nursing, and resident's daughter had all been made aware by that time.
The raised area on the resident's forehead decreased significantly and was almost gone within a day, according to the director of nursing. She stated there were no other injuries from the incident.
The director of nursing acknowledged that multiple staff members had failed to follow proper procedures. She told inspectors that nurses should have notified the physician immediately when the head injury was discovered, and that family notification should have occurred at 7:30 AM rather than waiting until evening.
Federal inspectors found the facility failed to ensure staff properly reported and assessed the head injury according to established protocols. The violation affected few residents but created potential for actual harm through delayed medical evaluation and family notification.
The nurse practitioner emphasized that immediate neurological assessments are standard protocol for any head injury, regardless of the circumstances. The 12-hour delay in starting these critical evaluations represented a significant departure from accepted medical practice for elderly residents with head trauma.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Chapters Living of Council Bluffs from 2026-01-30 including all violations, facility responses, and corrective action plans.