Failure to Assess and Monitor Bruising in Resident with Self-Injurious Behavior
Penalty
Summary
The facility failed to provide adequate assessment, monitoring, and documentation of a bruise observed under the left eye of a resident with schizoaffective disorder and a history of self-injurious behavior. The resident, who was cognitively intact and newly admitted for mental health and diabetes management, reported that the bruise was self-inflicted due to command hallucinations. Despite standing orders and care plan interventions requiring regular skin assessments, documentation of abnormal findings, and prompt follow-up for injuries, there was no evidence of a nurse's initial evaluation or ongoing monitoring of the bruise in the medical record. Nursing assistant documentation noted the presence of the bruise and communication to the charge nurse, but there was a lack of subsequent nursing assessment, measurement, or description of the injury in the progress notes or skin and wound documentation. The facility's policy and staff interviews confirmed that the expected process for non-pressure injuries included assessment, implementation of standing orders, provider notification, daily monitoring, and documentation until resolution. Additionally, an incident report and behavioral team notification were required if the injury was behaviorally related or of unknown origin. Despite these protocols, the only documentation related to the bruise was from the nursing assistant, with no follow-up by licensed nursing staff as required. The resident's care plan and physician orders emphasized the need for close monitoring due to his mental health condition and risk for self-harm, yet the facility did not ensure that the bruise was adequately assessed, monitored, or documented according to policy and physician orders.