Failure to Timely Develop Care Plan After Discovery of Bruising
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a care plan after bruising was observed on a resident. The resident, who had diagnoses including dementia and legal blindness, was dependent on staff for all activities of daily living and had severely impaired cognitive skills. On review of the resident's records, skin discoloration was first noted on the left mid-arm, under the left breast, and chest, and later spread to the left rib and back. Despite these findings, there was no documentation in the Treatment Administration Record (TAR) that the Treatment Nurse monitored the skin discoloration from the time it was first observed. The care plan addressing the resident's skin discoloration was not developed until two days after the initial discovery of the bruising, following the resident's return from the hospital. Interviews with nursing staff revealed confusion regarding responsibility for initiating the care plan, with one nurse stating she did not develop the care plan because she was not the assigned nurse, and another stating she created a care plan on the day the bruises were discovered. The Director of Nursing confirmed that the care plan should have been developed immediately upon discovery of the bruises, in accordance with facility policy and the Treatment Nurse's job description. Facility policy required licensed nurses to document changes in a resident's condition and update the care plan accordingly. The delay in developing a care plan resulted in a lack of timely interventions and monitoring for the resident's bruising, as evidenced by the absence of documentation in the TAR and the late creation of the care plan. This lapse potentially affected the delivery of care to the resident.