Request A Free Consultationcat-right

PARSONS, KS – No Neurologic Assessments Performed After Fall; Resident Dies


LOCATED: 1315 S 15th STREET, PARSONS, KS 67357


PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here.



The facility identified a census of 31 residents, with 4 residents sampled for accidents. Based on observation, interview and record review, the facility failed to thoroughly assess the neurological condition of 2 of the 4 sampled residents. Resident #1, an alert and oriented resident, did not receive neurologic assessments after an un-witnessed fall with self-reported hit to head which resulted in a subdural intracranial hematoma (an accumulation of blood in the subdural space). This deficient practice placed resident #1 in immediate jeopardy, and the resident expired at the hospital. The nurse’s note, dated [DATE] at 8:20 AM, documented the resident transferred to the hospital via facility staff. Review of the nurse’s notes from the time of the fall, on [DATE] at 3:30 PM, to the time of transfer to the hospital, on [DATE] at 8:20 AM, revealed the record lacked any documentation of any thorough neurological assessments.

Continued: Staff H reported the first time in the resident’s room he/she was talking normal, but by the 3rd time he/she wasn’t making any sense and had glassy eyes. Staff H had no idea the resident fell the day before, and was not told to check vital signs more frequently or do any increased visual checks on the resident. Staff H reported while dressing the resident, he/she noticed a fresh bruise on the resident’s back, about 3 inches in size with numerous tiny, pinpoint size purple dots inside the bruise. On [DATE] at 1:53 PM, Administrative Nursing Staff C reported the resident fell on [DATE] around 3:30 PM. The resident took off the personal body alarm and took him/herself to the bathroom, where he/she suffered an un-witnessed fall and struck his/her head, per the resident’s report. Staff C confirmed all post fall assessments should include initiation of neurologic assessments for any un-witnessed fall or if the resident hit their head. Staff confirmed this resident’s record lacked any complete neurologic assessments after the fall, and reported the nurse that worked at the time of the fall should have initiated them. The neurologic assessment should have been done initially to include any change in level of consciousness, resident’s orientation, pain, range of motion, grips of hands and status of pupils (PERRLA). Staff C confirmed that he/she worked the shift after the resident’s fall, beginning at 6:00 PM, approximately 2 hours after the resident’s fall, was aware of the fall and that the resident hit his/her head, and that Staff C also did not initiate neurologic checks on this resident. On [DATE] at 5:15 PM, Administrative Staff confirmed that neurologic assessments should have been initiated by the nurse at the time of the fall and were not done. Staff A confirmed that the next nurse that worked, should have realized that the neurologic assessments were not being done and started them, but did not. Staff A reported that the facility had just received word from the resident’s family that the resident died in the hospital earlier today.

Personal Note from NHAA Advocates: NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety. This nursing home and many others across the country are cited for abuse and neglect.

You can make a difference. If you have a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately. We can help you file a state complaint, hire a specialized nursing home attorney or help you find a more suitable location for your loved one.

Contact us through our CONTACT FORM located on our website here below or on the sidebar or call our toll free hot line number: 1-800-645-5262

You can make a difference even if your loved one has already passed away.

Click Here To Request A Free Consultation Today!

4 Responses to “PARSONS, KS – No Neurologic Assessments Performed After Fall; Resident Dies”

  1. Trinity Lawson says:

    It is blogs like these that make wonderful places look terrible when in fact what is typed up on a piece of paper does not portray the actuality of events. When an alert resident says they didn’t hit their head and are fine you believe them and don’t have to start neuro checks. The resident was fine all evening and night so regardless neuro checks would have made No difference in the outcome. This resident was one who had been at this nursing home a couple different times in the past. People don’t return to neglectful homes. He called the staff his family because his real family had abandoned him. Curious how this family jumped on suing his home of choice as soon as they could. Gary would have been very upset by this. No one at the home had ever seen this “concerned” family so instead of blogs about “neglectful” nursing homes how about blogs on neglectful fsmilies. Things are rarely black and white when it comes to state reports and this is a prime example of an unfortunate accident that was not going to have any other outcome. As soon as it was noted resident was in distress he was sent to the hospital Immediately. Articles like these make good places sound horrible when in fact that could be farther from the truth.

    • A concerned citizen says:

      Do you see an apology anywhere in ElmHaven’s response, NO and you won’t. The staff’s motto appears to be deny till you die. I have personally experienced various staff members at this facility lie about what they said when called to task. There is absolutely NO ACCOUNTABILITY, there is always an excuse for why they don’t do their jobs and NEVER an apology. If you have a family members in this facility I would take head and pay careful and pay close attention to your loved one, especially if they have lost the ability to speak for themselves.

  2. Debbie says:

    Nothing is ever black or white, but the fact that a licensed facility did not transport a patient who was known to be on blood thinners immediately upon notification of a fall is gross neglect. People return to homes they have been to before when the options are extremely limited. This “patient” was not abandoned by his family. 90% of his family lived over 100 miles away from this facility and visited as often as possible. This “patient” was well loved by his family and his family has been robbed after neglect by this facility. Most nursing home patients are in nursing homes because they are unable to care for themselves and unaware of whether they are “fine” or not. Standard procedure would be to immediately transport a patient on blood thinners, despite whether they “appear” to be fine. Please don’t paint this family as neglectful because they lived in different states from the “patient”.

  3. Anonymous says:

    Neuro checks are required following an unwitnessed fall, even if the resident is usually alert and oriented. Thorough neuro checks would have prompted quicker transfer to the hospital, which could have meant a better outcome for the resident. Whether you like it or not, the nurse did in fact neglect the resident and failed to follow policies that are standard in all nursing homes.


Your email address will not be published. Required fields are marked *