Failure to Timely Assess and Report Large Bruise Following Resident Fall
Penalty
Summary
A deficiency occurred when a resident with a history of malignant neoplasm of the kidney, type 2 diabetes mellitus, and heart failure did not receive timely assessment and reporting of a large bruise on the left outer leg, extending from the knee to midcalf. The resident was cognitively intact and required one-person assistance for bathing, dressing, and toilet use. The bruise was first documented by physical therapy on 7/15/2025 as being tender to the touch, and the resident reported pain in the left knee. The resident also reported to staff that they had fallen, and this was communicated to the medical provider. However, the Accident and Incident Report indicated the fall occurred on 7/08/2025 or 7/09/2025, suggesting a delay in recognition and reporting. Further review revealed that weekly skin checks, as ordered, were not documented as completed on 7/01/2025 or 7/08/2025 in the Treatment Administration Record. Interviews with staff confirmed that all ordered care should be provided and documented, and that new bruises or skin issues identified by CNAs should be reported immediately to the charge nurse. The Director of Nursing acknowledged that weekly skin checks should have been completed and signed for, and that the bruise should have been reported promptly. The lack of timely assessment and documentation led to the deficiency.