Failure to Document Ongoing Skin Changes for Resident on Anticoagulant
Penalty
Summary
The facility failed to document ongoing skin changes for a resident who was prescribed an anticoagulant and had known bruises. According to the facility's Intensive Skin Care Program, direct care staff are required to perform daily skin inspections and report any new redness, discoloration, or discomfort to the charge nurse for assessment and intervention. The Medical Records policy also requires that records be kept current, with entries detailing the resident's condition and nursing goals. Despite these policies, the clinical record for the resident showed no documentation of bruising on the upper extremities after an initial note on 1/31/25, even though multiple deep purple bruises were observed on both forearms during a later survey. Interviews with nursing staff and certified nursing assistants confirmed awareness of the resident's bruises and the fact that the resident was on a blood thinner, which can cause bruising. However, there was no further documentation in the clinical record or care plan regarding the size, location, or description of the bruises after the initial entry. The Chief Nursing Officer confirmed that the last documentation of the bruising was several months prior, and acknowledged that ongoing documentation should have occurred.