Failure to Assess and Document Resident's Skin After Reported Injury
Penalty
Summary
A deficiency occurred when a resident reported bumping her forehead on a handrail while sitting on the commode, resulting in a small, faint bruise. The incident was disclosed by the resident the following day, at which time she denied pain, dizziness, or blurred vision. The resident's daughter and physician were notified, and the interdisciplinary team reviewed the incident. However, there was no evidence in the medical record that a skin assessment was performed following the incident. The Director of Nursing confirmed that the registered nurse who spoke with the resident did not complete a full skin assessment after the resident reported the injury. Facility policy requires documentation of the incident, including first aid, vital signs, and results of a physical assessment such as bruises or other injuries. The lack of a documented skin assessment following the reported incident constituted non-compliance with facility policy.