Objective: Hourly neurological examinations are frequently performed in the neurointensive care unit (NICU) to quickly detect neurological deterioration. These examinations require the patient to be awakened hourly for days disrupting the sleep cycle and potentially causing neurological deterioration through sleep deprivation and the development of delirium. This pilot study’s aim was to describe the prevalence of neurologic deterioration and delirium in patients receiving hourly neuro checks. Design: A 6-month prospective observational cohort study was conducted within the NICU at Mayo Clinic Florida. Twenty subjects were enrolled between July 24, 2016, and January 30, 2017. Results: Neurological deterioration as defined as a decrease in Glasgow Coma Scale score of 2 or more, an increase in National Institute of Health Stroke Scale score by 4 or more, or a change in Confusion Assessment Method score for use in intensive care unit patients from negative to positive occurred in 19 of 20 patients (95%) for a total of 67 events, with most patients having multiple events. Seventy-five percent of the subjects experienced a decrease in Glasgow Coma Scale score of 2 or more at least once during the study period. The largest number of events occurred within the first 24 hours (39%). Surprisingly, 75% of the subjects also developed delirium. Forty percent of the subjects demonstrating neurological deterioration received computed tomography imaging to evaluate the change. Sixty-seven percent lacked deterioration evident on computed tomography imaging, and the deterioration was not attributed to medication effect or seizure by an experienced provider. Conclusions: Neurological deterioration is prevalent in the NICU population. Although hourly neurological examinations may be beneficial in the acute phase of neurological injury, prolonged use may be paradoxically harmful due to sleep deprivation.