Failure to Document and Monitor Unexplained Bruise
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for one resident who was reviewed for accidents and supervision. The resident, a female with a history of type 2 diabetes, right-sided paralysis, muscle weakness, difficulty walking, high blood pressure, and a history of falls, was found to have a dark purple bruise with a red edge on her sternum. The resident was unable to recall how the bruise occurred and denied any pain or recent falls. Multiple skin assessments conducted by the Wound Care Nurse over several weeks did not document the presence of a bruise on the sternum, and there was no incident or accident report related to this injury. Interviews with staff revealed that the bruise had been present for some time, but there was no documentation or clear understanding among staff regarding its origin. The LVN stated that the bruise was not documented in any accident or incident reports, and the Wound Care Nurse was unaware of the bruise on the sternum, having only followed a wound on the resident's neck. The DON confirmed that staff are expected to document new bruises and monitor them daily, but acknowledged that there was no documentation of the sternum bruise in the resident's chart. The DON attributed the lack of documentation to staff assuming the bruise was related to a previous fall, but the records did not support this conclusion. The facility's policy requires that all incidents and accidents, including unobserved injuries, be documented and assessed by licensed staff, with ongoing documentation until resolution. In this case, the failure to identify, document, and monitor the resident's sternum bruise represented a lack of adequate supervision and failure to follow established protocols for accident and injury management.