Failure to Prevent and Address Resident Bruising Due to Inadequate Supervision and Hazard Mitigation
Penalty
Summary
A deficiency occurred when the facility failed to ensure the environment was free from accident hazards and did not provide adequate supervision or interventions to prevent accidents for a resident with multiple medical conditions, including dementia, atrial fibrillation, and use of blood thinners. The resident, who had severe cognitive impairment and required supervision or assistance with transfers, toileting, and eating, was found with multiple bruises on her arms and legs after a shower. The facility's assessment did not determine the root cause of the arm bruises, and there was no documentation or evidence that interventions were added to the care plan to prevent recurrence. Possible causes such as rolling up compression stockings, hard toilet and shower chair surfaces, and the resident's combativeness during care were identified but not addressed through new interventions or care plan updates. Additionally, the facility did not provide education to staff on ways to prevent injury or recurring bruises following the incident, despite documentation indicating that education was completed. Staff statements and interviews revealed a lack of follow-up on potential causes and no new measures to protect the resident's skin or mitigate combativeness during care. The facility's records and critical event forms did not reflect any assessment or intervention to address the identified hazards, resulting in a failure to prevent further injury and ensure the resident's environment was as free from accident hazards as possible.