Failure to Notify Physician and Family After Resident Fall and Skin Injury
Penalty
Summary
Staff failed to notify both the physician and the family of a resident after a fall that resulted in a skin condition. Clinical record review showed that a nurse documented a bruise on the back of the resident's right leg, measuring 2 cm by 4 cm and described as yellow, green, and purple. The progress notes did not indicate that the physician or family had been informed of the injury. Additionally, the facility did not complete the required skin sheet to monitor the bruise on a weekly basis as per their policy. The resident involved had diagnoses of schizophrenia, depression, and orthostatic hypotension, and was assessed as having no cognitive impairment. Facility policy required that any new skin alteration be assessed, documented, and reported to the physician, with appropriate treatment orders and care plan updates. However, these steps were not followed in this case, as the required notifications and documentation were not completed.