Failure to Notify Physician of Resident's Unknown Injury and Bruising
Penalty
Summary
A deficiency occurred when the facility failed to notify a resident's primary care physician (PCP) of an unknown injury involving significant bruising. The resident, who had a history of congestive heart failure, muscle weakness, cirrhosis of the liver, diabetes, and hypertension, was found during a shower to have large areas of discoloration on her right forearm, right arm, right inner thigh, right breast, and the inside of her left arm. The resident was on Plavix, an antiplatelet medication, and her care plan included monitoring for signs of bleeding or bruising and reporting these to the physician. Documentation showed that administration was notified of the bruising, but there was no evidence that the PCP was informed as required by facility policy. The incident was also reported as a self-reported incident (SRI) and an incident report was completed, both noting the extensive bruising and the resident's lack of awareness of how the injuries occurred. Interviews with the resident and the Director of Nursing (DON) confirmed that the PCP was not notified of the unknown injury. Facility policies required prompt physician notification for changes in condition, including injuries of unknown source, especially for residents on anticoagulation therapy. Despite these requirements, there was no documentation or evidence that the physician was contacted regarding the resident's condition.
Plan Of Correction
Resident #9 was immediately assessed and found to have no adverse effects. Open Risk assessments audited by DON to ensure all physicians were notified on 5/22/25. All residents have the ability to be affected. Education on appropriate physician notification for resident change in condition was provided by DON to all staff on 5/22/25. DON/designee to audit 2 charts a week for 4 weeks to ensure PCP was notified of change in condition. Results to be reviewed in QAPI.