El Dorado Care: Ignored Head Injury Goes Unnoticed - KS

Federal inspectors discovered the oversight during their annual survey of El Dorado Care and Rehab on April 6, when they observed Resident 8 in his bed with a visible injury measuring approximately half a centimeter by two centimeters on the right side of his forehead.

The resident shook his head side to side when inspectors asked if he had fallen.

Resident 8 suffers from chronic respiratory failure and schizophrenia. His medical records show he is nonverbal, rarely communicates, and requires total assistance for all activities of daily living. Staff assessments revealed severely impaired cognition, and he could not complete basic mental status evaluations because he was rarely or never understood.

His care plan, dated April 26, 2023, specifically instructed staff to inspect his skin weekly and as needed. Staff were directed to observe for redness, open areas, scratches, cuts, and bruises, and report any changes to the nurse immediately.

But weekly skin inspection notes from March 28 and April 2 contained no documentation of any abrasion or bruise on the resident's forehead.

Staff did not document the injury until the following day, April 7, at 5:10 PM — more than 32 hours after inspectors first observed it. By then, the progress note described the abrasion as purple and slightly larger, measuring 0.3 centimeters by 2.5 centimeters.

The resident was unable to describe how the injury occurred. When staff questioned each other about the origin of the injury, no one could identify any event that might have caused it.

The progress note speculated that the resident's head "may have hit the wall during cares." Staff noted that Resident 8 had recently been moved to a different room, and his bed was placed against the wall. They placed a fall mat to the left side of his bed to prevent him from "grazing his head on the wall."

Certified Nurse Aide O told inspectors on April 7 that she had not noticed the abrasion or redness on the resident's forehead. When interviewed that afternoon, she acknowledged that any new skin issue identified on a resident should be reported to the nurse, and that staff were required to write a statement for injuries such as bruises or skin tears.

Licensed Nurse J reported that the night nurse on April 6 had told her that Resident 8 had an abrasion on his forehead, but she was not sure how it happened. The licensed nurse said she did not document the area on the resident's forehead because she thought the night nurse had already done so.

Neither nurse had documented the injury.

Administrative Nurse E told inspectors on April 7 that she was not aware Resident 8 had an abrasion on his forehead. She acknowledged that the nurse should have reported, assessed, and completed a risk management report for the abrasion.

She also stated that a root cause analysis should have been completed to assess how the resident would have received the injury.

The facility's failure violated federal regulations requiring nursing homes to ensure that residents receive treatment and care in accordance with professional standards of practice. The deficiency was classified as causing minimal harm or potential for actual harm to a few residents.

Resident 8's vulnerability made the oversight particularly concerning. His diagnoses of chronic respiratory failure mean his respiratory system fails to properly exchange oxygen and carbon dioxide, resulting in persistently low oxygen levels. His schizophrenia involves gross distortion of reality, disturbances of language and communication, and fragmentation of thought.

The resident's complete dependence on staff for all care, combined with his inability to communicate effectively, left him entirely reliant on staff vigilance to identify and address injuries or changes in his condition.

The facility's own care protocols recognized this vulnerability by requiring weekly skin inspections and immediate reporting of any changes. Staff were specifically trained to look for the exact type of injury they failed to identify — redness, scratches, cuts, and bruises.

The delayed response meant that whatever caused the resident's injury went uninvestigated for more than a day, potentially allowing dangerous conditions to persist. The speculation about the resident hitting his head on the wall during care suggested possible rough handling or inadequate protection during routine activities.

The placement of a fall mat only after the injury was discovered indicated reactive rather than preventive care. If staff suspected the resident might graze his head on the wall due to his room placement, protective measures should have been implemented before an injury occurred.

The communication breakdown between nursing staff compounded the problem. The night nurse apparently identified the injury but failed to document it. The day nurse relied on the night nurse's documentation that never materialized. The administrative nurse remained unaware of the situation entirely.

This chain of failures left a vulnerable resident without proper assessment, treatment, or investigation of a visible head injury for more than 24 hours. The resident's inability to advocate for himself or explain what happened made staff vigilance his only protection.

The facility's acknowledgment that risk management protocols and root cause analysis should have been completed highlighted the systematic nature of the failure. These processes exist specifically to prevent similar incidents and protect other vulnerable residents.

Federal inspectors completed their survey on April 9, documenting the violation as part of their annual review of the facility's compliance with health and safety standards.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for El Dorado Care and Rehab from 2026-04-09 including all violations, facility responses, and corrective action plans.

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