Failure to Assess and Report Change in Resident's Arm Condition
Penalty
Summary
Facility staff failed to assess and report a significant change in a resident's condition after a left arm bruise was observed and reported to a licensed nurse. The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was admitted with a pre-existing bruise on the left arm. Over time, the bruise increased in size, and on the day in question, a certified nurse assistant noticed the resident protecting her arm and observed a large purplish bruise, which was reported to the licensed vocational nurse (LVN). The LVN, upon being informed, checked the resident's chart and noted the bruise had been documented at admission but did not physically assess the resident. The LVN instructed the CNA to notify the treatment nurse. The treatment nurse, a registered nurse (RN), also reviewed the chart and did not assess the resident's arm, believing it was not a change in condition. Both the LVN and RN acknowledged during interviews that an assessment should have been performed to determine if there were any changes to the resident's skin or condition. Subsequently, the resident was found to have an acute fracture of the left humerus, as indicated by a radiology report. The facility's policies required prompt assessment and notification of changes in a resident's condition, including new or worsening injuries. The failure of staff to assess and report the change in the resident's arm condition resulted in a delay of care and was identified as a deficiency during the survey.