Failure to Identify and Document New Bruise During Skin Assessment
Penalty
Summary
A deficiency occurred when staff failed to identify and document a new bruise on a resident with morbid obesity and type II diabetes mellitus, who required substantial to maximal assistance with upper body dressing and had intact cognition. The resident had an active physician's order for weekly skin assessments and care plans directing staff to monitor and report changes in skin integrity, including bruises. During a surveyor's observation, a fading bruise was noted on the resident's left forearm, which the resident was unaware of how it occurred and reported no pain. Review of the resident's recent skin assessments showed no documentation of the bruise, and staff interviews revealed that the CNA who last cared for the resident did not observe any bruises at that time. The CNA and nurse both confirmed that any new bruises should be reported and documented, but neither was aware of the bruise prior to the surveyor's observation. The Director of Nursing also confirmed that the bruise should have been identified and documented during the weekly skin assessment, but it was not.