Failure to Identify and Document Resident Bruising
Penalty
Summary
The facility failed to identify, assess, and implement interventions for a resident who exhibited multiple undocumented bruises on her body. The resident had severely impaired cognitive functioning, required substantial to maximal assistance with activities of daily living, and had a history of falls and skin picking. Despite care plan directives for weekly skin assessments and specific interventions for skin concerns, documentation and assessment of new bruises were not completed as required. Photographic evidence showed bruising on the resident's forehead, knees, and buttocks over several days, but these were not recorded in the weekly skin observation tools, which indicated no new skin issues during the same period. Interviews revealed that CNAs did not alert nurses to new skin concerns, assuming nurses were already aware due to prior assessments after a fall. The facility's policy required thorough documentation, including physician and family notification, completion of incident reports, and investigation of causation for any abrasions, skin tears, or bruises. However, these steps were not followed for the resident's bruises, resulting in a lack of appropriate assessment and intervention according to the resident's care plan and facility policy.