Failure to Document and Report Change in Resident Condition
Penalty
Summary
The facility failed to ensure that nursing staff documented a resident's change in condition according to professional standards and facility policy. Specifically, a resident with a history of traumatic subdural hemorrhage and chronic pain was found with a laceration to the lip and a contusion to the left orbital area. The incident occurred early in the morning, and the resident reported to the nurse that he had bitten his lip. The nurse observed the injury but did not document the change in the resident's condition in the medical record, nor did she notify the oncoming nurse, the physician, or the resident's family as required by facility policy. Subsequently, the oncoming nurse was alerted to the resident's injuries by a CNA and, upon assessment, found a bleeding cut and a black eye, prompting immediate notification of the DON, physician, and family, and transfer of the resident to the emergency department. Review of the emergency department documentation confirmed the presence of a facial laceration requiring sutures and a contusion. Interviews with facility staff and review of records confirmed that the initial nurse did not follow the required procedures for documenting and reporting the change in the resident's condition.