Failure to Assess and Monitor Resident's Bruising, Swelling, and Pain After Transfer Incidents
Penalty
Summary
Facility staff failed to adequately monitor and assess a resident who experienced bruising, increased swelling, and pain following two transfer incidents. The resident, who was cognitively intact but dependent on staff for mobility and personal care, had multiple complex medical conditions including chronic respiratory failure, atrial fibrillation, heart failure, pneumonia, COPD, and depression. The resident was also on anticoagulant and diuretic therapy, and required oxygen and non-invasive mechanical ventilation. After two transfer events, one involving a fall with a gait belt and another with a sit-to-stand mechanical lift, the resident developed multiple bruises on the left lower leg and ankle. Although staff noted bruising and swelling, there was no documentation of a thorough assessment, including the number or size of bruises, nor was there evidence of ongoing monitoring or pain assessments in the medical record. The facility's policy required identification and documentation of changes in a resident's baseline status, but this was not followed for the resident's evolving symptoms. Despite repeated complaints of pain, increased swelling, and visible bruising over several weeks, staff did not complete or document appropriate assessments or monitoring. The physician was notified of the symptoms, and imaging was eventually performed, revealing a nondisplaced fracture of the left ankle and a fracture of the lower left fibula. There was no evidence that staff followed up on abnormal imaging findings or consistently monitored the resident's pain and condition during this period.