Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that injuries of unknown origin were reported within 24 hours, as required by their Abuse Prevention policy. This deficiency was identified for a resident who had a bruise of unknown origin on the left forearm, which was not reported by the Certified Nursing Assistant (CNA) who discovered it. The CNA, who worked the night shift, observed the bruise during their shift but did not report it, assuming someone else had already done so. This lack of reporting was contrary to the facility's policy, which mandates immediate reporting of any changes in skin integrity to the nurse in charge. The resident involved had a history of a Stage III Pressure Ulcer and repeated falls, with intact cognition and no behavioral symptoms. The resident required assistance with daily activities and had no functional limitations in the upper and lower extremities. Despite regular skin assessments and care plans in place, the bruise was not documented until observed by surveyors. Interviews with various staff members, including the LPN and Wound Care RN, revealed that they were unaware of the bruise until it was pointed out during the survey. The Director of Nursing Services confirmed that the CNA should have reported the bruise, and an investigation was initiated once the issue was brought to their attention.
Plan Of Correction
Plan of Correction: Approved February 24, 2025 A: Immediate Correction Action 1. Resident #273 who still resides at the facility was affected by this deficient practice. 2. An Accident and Incident report was initiated. 3. Nursing Assistant #6 was counseled and re-educated on 1/30/25 Abuse Prevention and Reporting. B: Identification of Others 1. All residents that reside in the facility have the potential to be affected by this deficient practice. 2. The facility conducted a skin assessment on 20 random residents to see if there were any changes in skin condition that were not reported. There were no findings noted. C: Systematic Review to prevent re-occurrence 1. The DNS devised an audit tool to ensure that all skin changes are reported and documented in a timely manner with the proper notifications to MD, family and governmental agencies if applicable. 2. The facilities policy titled Abuse Prevention dated 10/22 was reviewed by the Administrator, Medical Director and DNS and no changes were made. 3. The facilities policy titled Potential for Risk in Skin Integrity Prevention and Treatment dated 5/2011 was reviewed by the Administrator, Medical Director, and DNS and no changes were made. 4. The RN Nurse Educator will re-educate all nurses, CNA's, housekeeping, maintenance, recreation, dietary, pastoral care, and ancillary staff on Abuse Prevention and Reporting. 5. The RN Nurse Educator will re-educate all CNA’s on monitoring the resident’s skin during ADL’s and reporting any skin changes to the nurse. D: Quality Assurance 1. The DNS and or designee will audit 10 residents weekly x 3 months and thereafter monthly for 1 year until 100% compliance is obtained to ensure that there have been no undocumented skin changes. 2. Any negative audit findings will immediately be addressed by the DNS/ designee with an onsite teaching/in-service, and disciplinary action as needed. 3. The DNS will report the findings of this audit quarterly at the QAPI meeting. 4. The DNS/ designee is responsible for ensuring the correction of this deficient practice.