Failure to Monitor Bruises and Timely Implement Wound Orders
Penalty
Summary
The facility failed to properly monitor and document the progression of a bruise for a resident with significant cognitive impairment and multiple complex diagnoses, including dementia, hemiplegia, and malignant neoplasm. After a bruise was noted on the resident's right eye, an order was given to monitor the area every shift until resolved. However, from the time the bruise was first documented until it was considered healed, there was no ongoing documentation describing the size, condition, color, or other relevant characteristics of the bruise, aside from the initial assessment. The care plan addressing the bruise was not implemented until several weeks after the injury had resolved, and the facility was unable to provide requested documentation supporting that the bruise was properly monitored during the specified period. Additionally, the facility did not implement wound care orders in a timely manner for another resident with severe cognitive impairment and multiple medical conditions, including hemiplegia, diabetes, and a burn wound. Although a physician's order was in place to provide specific wound care, there was a delay in updating and carrying out the correct treatment due to a system changeover. The unit manager confirmed that the correct order was not timely implemented and was unable to provide evidence that the prescribed wound care was administered as ordered. These deficiencies demonstrate lapses in both the monitoring and documentation of skin conditions and the timely implementation of physician-ordered treatments for residents with complex medical needs. The lack of proper documentation and timely care interventions directly affected the residents reviewed for skin conditions during the survey.