Failure to Document and Assess Resident After Incident
Penalty
Summary
The facility failed to ensure appropriate care in accordance with professional standards of practice for a resident with skin conditions. On a specific date, a resident was hit in the face with a bed control while being cared for by a Certified Nurse Aide. The incident was reported to a Licensed Practical Nurse (LPN), who observed no immediate injury and did not document the incident or report it to a nursing supervisor. The resident, who was on blood thinners and had severely impaired cognition, was not assessed by a Registered Nurse as required. Subsequently, another LPN was informed of the incident during a shift change but also failed to document the occurrence or report it to a supervisor. Although no immediate bruising was noted, bruising appeared in the following weeks, which was not documented. The Director of Nursing confirmed that the incident was not reported to the nursing supervisor and acknowledged that a Registered Nurse should have assessed the resident. The lack of documentation and failure to follow proper reporting and assessment protocols led to the deficiency.
Plan Of Correction
Plan of Correction: Approved April 4, 2025 F684 I. Immediate Corrective Action: 1) Resident # 10 was assessed by the MD and no untoward persisting effects of the bruise on the resident’s face were noted. 2) A full body assessment was done for Resident # 10 by the RN Supervisor to assess for any unknown bruises. None were found. 3) Resident # 10 was assessed by the SWD and no signs of psychosocial distress were noted. 4) The IDT Team reviewed Resident # 10 CCP and CNAAR for specific interventions. The Resident is determined to have all interventions in place needed. II. Identification of Others 1) The Facility respectfully states that all residents were potentially affected. 2) The DON will review all accidents/incidents for the past 30 days to ascertain if there were any injuries of unknown origin that required further investigation: No issues were identified. III. Systemic Changes 1) The DON in conjunction with the Administrator reviewed the facility’s policy titled Accident/Incident Reporting and Investigation and found same to be compliant. 2) The policy and procedure will be re-in serviced to all registered nurses, licensed practical nurses, and certified nurse assistants by the Designee. The lesson plan will focus on: - The responsibility of all direct care staff to report any incident involving or during resident care to the Unit Charge Nurse and/or RNS - The responsibility of all direct care staff to report any injuries of unknown origin including bruising, redness, or skin changes - The chain of command for reporting events involving residents includes: the CNA will report to the unit LPN, then the unit LPN will report to the unit charge nurse and/or RN Supervisor. - Immediate assessment of the resident by the RN Supervisor and initiation of A/I report. - RN Supervisor to inform the physician and carry out any orders. - MD/NP will also assess resident and document any findings. - RN Supervisor to inform the designated health care representative of incident/change in condition and plan of care. - Licensed nurse to document in the resident’s medical record as well as the 24-hour report. - The responsibility of the DON and Administrator to investigate and report to NYSDOH any injuries of unknown origin. IV. Quality Assurance: 1) The DON developed an audit tool to monitor the facility’s compliance with ensuring an RN assessment and investigation is conducted for all incidents/accidents involving residents. 2) 4 Randomly selected incidents will be audited weekly for 4 weeks and monthly for 11 months. 3) All findings will be brought up at the QA Meeting for input and correction as needed. V. Person Responsible: Director of Nursing