Failure to Assess and Document After Resident Reported Rough Care and Bruising
Penalty
Summary
The facility failed to complete an assessment when a resident reported bruising related to a staff member being rough during care. The resident, who had a history of a fall at home resulting in a right hip hematoma and multiple bruises, was admitted to the facility with documented bruising on her legs and hips. Despite weekly body audits, the documentation did not include measurements of skin alterations, and there was inconsistency in the recorded location of the hematoma. The resident and her daughter reported concerns to nursing staff about rough handling by an overnight staff member, but the staff could not identify the specific individual involved. Staff interviews revealed that the LPN who received the complaint reported it to the charge nurse but did not document an assessment or complete an occurrence report as required by facility policy. The LPN stated that it was difficult to determine if new bruising was present due to the pre-existing bruises from the resident's fall at home. The Director of Nursing and the Administrator both acknowledged that an assessment should have been completed in response to the report of rough care, but no such assessment was found in the resident's records. Facility policy required that any employee discovering or observing an event report it to a supervisor so that immediate and necessary action could be taken, including completion of an occurrence report. However, the lack of documentation and assessment following the resident's report of rough handling constituted a failure to provide appropriate treatment and care according to orders, resident preferences, and goals.