Failure to Document and Notify Change in Resident Condition
Penalty
Summary
The facility failed to identify and document a change in condition for one resident who was observed with scratches on her nose. Despite the presence of dried blood and scabs, there was no documentation in the medical record regarding the new skin condition, nor was there a change in condition evaluation completed. Staff interviews revealed that neither the Certified Nursing Assistant nor the LPN on duty knew how the scratches occurred, and the skin assessment completed did not mention the new injuries. The Unit Manager acknowledged awareness of the scratches and claimed to have notified the family and physician, but admitted that no documentation of these notifications or the incident itself was made in the resident's record. Further investigation showed that the behavior of the resident scratching herself was not care planned, and there were no progress notes or assessments related to the incident. The resident had severe cognitive impairment, as indicated by a low Brief Interview for Mental Status score. Interviews with the resident's family confirmed that they were not informed about the scratches, nor were they aware of any habitual scratching behavior. Staff described a process for reporting and documenting new injuries, but this process was not followed in this case, resulting in a lack of required notifications and documentation.