Failure to Complete and Document Full Assessment After Injury of Unknown Origin
Penalty
Summary
A resident was found to have a bruise on the forehead, which was first identified by a family member and brought to the attention of facility staff. The facility administrator became aware of the injury after it was pointed out by the family. Upon review, there were no progress notes or documentation in the resident's medical record regarding the bruise on the day it was discovered. Additionally, there were no skin assessments recorded for that day. The LPN on duty at the time confirmed being present when the bruise was found but did not recall the specifics of the incident. The LPN stated that they did not assess the rest of the resident's body for additional injuries and were unaware that a full assessment and documentation were required when a new injury was discovered. The DON later confirmed that the LPN had not followed their training, as a complete assessment should have been performed to ensure there were no other injuries.