Failure to Prevent and Report Resident Injury During Care
Penalty
Summary
A deficiency occurred when a resident, who was cognitively intact and diagnosed with Parkinson's Disease, sustained a skin tear on her right forearm during care. The resident reported that an aide scratched her with her nails while providing care, and this was corroborated by the resident's daughter, who noticed the bandage and was told by her mother about the incident. Observation confirmed the presence of a bandage on the resident's right arm. Despite the injury, there was no immediate documentation or physician order regarding the skin tear in the resident's record at the time of initial review. The wound care nurse was unaware of the injury until the following day, and the DON confirmed that the incident had not been reported to her. The facility's policy requires prompt reporting and action to prevent accidents, but this process was not followed, resulting in a lack of timely assessment and documentation of the resident's injury.