Failure to Monitor and Document Bruising for Cognitively Impaired Resident
Penalty
Summary
The facility failed to properly assess and monitor bruises for a resident with severely impaired cognition, Parkinson's disease, dementia, and significant physical limitations. The resident was dependent on staff for all activities of daily living and had an order for weekly skin monitoring, as well as a specific order to monitor bruising to the inner thighs after staff observed multiple greenish, fingerprint-sized bruises. Documentation showed that the order to monitor the bruises lacked clear directions and frequency, and was not entered into the Treatment Administration Record (TAR), resulting in inconsistent monitoring and documentation. Progress notes were missing for several days following the discovery of the bruises, and staff interviews confirmed a lack of awareness and follow-through regarding the monitoring order. The incident report and progress notes indicated that the medical provider was not notified at the time of the incident, and the order to monitor the bruises was not effectively communicated or implemented among nursing staff. The DON and other staff acknowledged that the order should have been placed in the TAR with a specified frequency to ensure consistent monitoring, but this was not done. As a result, there was no documented evidence that the resident's bruises were assessed every shift or daily as would have been expected, leading to a failure in providing appropriate treatment and care according to orders and the resident's needs.