Failure to Report and Document Resident Bruising
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to report the discovery of bruising on a resident's chest, left breast, flank, and left arm to the charge nurse or supervisor. The CNA found the bruises during a shower and did not complete the required skin assessment form or notify the appropriate staff, stating she became busy and did not follow through. The CNA acknowledged the importance of reporting such changes as it constitutes a change of condition that requires staff awareness and monitoring. Additionally, the treatment nurse (TN) who later discovered the resident's bruising did not document her findings in the resident's records. The TN admitted she was supposed to document the location and color of the bruises, as well as monitor and record any changes, but failed to do so. The TN stated she notified the Director of Nursing (DON) verbally but did not complete the necessary documentation or ongoing monitoring in the Treatment Administration Record (TAR) for the relevant period. The resident involved had significant cognitive impairment, was nonverbal, and was dependent on staff for all activities of daily living. The facility's policies and job descriptions required timely reporting and documentation of changes in resident condition for immediate intervention. The lack of reporting and documentation by both the CNA and TN delayed the resident's care and services, as staff were not made aware of the change in condition in a timely manner.