Resident #30 had a red area on the right side of her forehead discovered at 7:30 AM on January 4th. Staff failed to immediately alert the physician, start neurological assessments, or contact her family as required by facility protocols.
The injury wasn't reported to the on-call provider until 7:27 PM that evening, when staff faxed notification about a "3 cm x 2.5 cm hematoma to the right forehead of unknown origin." By then, what started as a red area had developed into a raised hematoma that concerned the resident's daughter when she visited that afternoon.
The Director of Nursing acknowledged multiple protocol failures. "I would have expected the staff would have notified the DON at 7:30 AM on the day the injury was found," she told inspectors. "I expected the nurse would have notified the physician of the area on the head at 7:30 AM when it was found as well and that was not completed."
Neurological assessments should have begun immediately when the forehead injury was discovered. Instead, the facility's electronic health record shows neurological monitoring didn't start until 6:00 PM that day, nearly 11 hours after the injury was first noticed.
The resident's family also wasn't notified until evening. The daughter had visited in the afternoon and asked about the raised area on her mother's forehead, apparently unaware of the morning discovery. The Director of Nursing said the daughter "must have forgotten about the earlier notification," but records show no early family contact occurred.
The incident followed a difficult night for Resident #30, who had been "aggressive and combative" the evening before. The Director of Nursing explained the resident "had kicked an employee in the groin and hit an employee" during that shift.
When questioned about the forehead injury, Resident #30 gave staff conflicting explanations. She told them she had hit her head on the bedside table the morning the injury was discovered. Staff also noted she had showered the day prior but reported no falls during that time.
The facility's Nurse Practitioner, contacted on January 13th, confirmed she wasn't made aware of the resident developing a "goose egg" after the initial contusion. "I would expect staff to call with any head injuries and start neuro assessments immediately," she told inspectors.
The Director of Nursing explained her decision-making process for neurological monitoring was flawed. She said she asked Staff M if Resident #30 was on blood thinners, and when told no, initially decided against immediate neuro assessments. "I would have only started neuro assessments if the resident was on a blood thinner and had an injury to the head of unknown origins or a change in cognition," she explained.
However, the facility's own protocols required immediate neurological monitoring for any head injury, regardless of medication status. The Director of Nursing later acknowledged that "neuro assessments should have been initiated when the area was found on Resident #30 forehead at 7:30 AM."
The hematoma resolved relatively quickly. "The raised area was only there for about a day and had decreased and was almost gone the next day," the Director of Nursing noted. No other injuries resulted from the incident.
By evening on January 4th, medical complications emerged. Staff held the resident's propranolol medication due to low blood pressure of 102/50 and a pulse of 53. When they called the on-call provider about these vital signs, no return call was received.
The Director of Nursing completed an investigation after the incident and interviewed staff members. She determined the injury likely occurred during the resident's combative episode the night before, despite the resident's account of hitting the bedside table that morning.
The facility acknowledged the injury was "no longer of unknown origins" following their internal investigation, but the 12-hour delay in proper notification and assessment protocols had already occurred.
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.