Failure to Timely Assess and Document Resident's Neck Lump
Penalty
Summary
A deficiency occurred when a resident with a history of schizoaffective disorder, alcohol dependence, and nicotine dependence reported a lump at the back of his neck. The resident stated that a family member had likely informed the nurse about the lump. Despite an email from the County Case Manager to the facility's RN requesting an assessment of the lump, there was no documentation in the resident's progress notes indicating that an assessment was performed or that the physician was notified. The RN acknowledged receiving the request and stated that only the front of the resident's neck was checked, not the back where the lump was located. The RN did not document any findings or respond to the County Case Manager's follow-up email. The Director of Nursing confirmed that nurses are expected to assess residents when concerns are raised by family members and to document all findings and actions in the medical record. The facility's policies require comprehensive assessments and documentation of all services provided. In this case, the lack of timely assessment, failure to notify the physician, and absence of documentation regarding the resident's lump constituted the deficiency.