Failure to Assess and Document Unexplained Bruising
Penalty
Summary
A resident admitted for a 7-day respite stay, with diagnoses including Alzheimer's Disease, severe protein-calorie malnutrition, and diabetes, was found to have multiple bruises of various stages of healing on discharge. Initial nursing and nurse practitioner assessments documented no skin integrity issues or visible rashes upon admission. The resident, who was severely cognitively impaired and required significant assistance with activities of daily living, was later observed by a CNA to have redness on the right arm on the day of discharge, which was reported to a nurse, though the specific nurse was not recalled. Documentation submitted to the State Agency included photos of bruises on the resident's neck, left shoulder, hand, chest, and shin, with some bruises appearing to be more advanced in healing than others. The facility's internal investigation could not substantiate the causes of all the bruises except for the hand, and the DON acknowledged that staff should have noticed the bruising during care. The facility's wound care policy required CNAs to check residents' skin daily and report any new findings to the charge nurse or unit management for immediate intervention, but this process was not followed, resulting in the failure to thoroughly assess and document the resident's skin bruising and injury of unknown origin.