Failure to Timely Assess and Intervene After Resident Change of Condition
Penalty
Summary
The facility failed to timely assess and implement interventions after a change of condition for two residents, resulting in delays in assessment and treatment. In the first case, a resident with severe cognitive impairment and dependence for activities of daily living sustained a deep laceration to the right hand during care when the resident grabbed a side rail while being turned. The incident was initially reported by the geriatric nursing assistants to an LPN, but there was no immediate nursing assessment or documentation. The injury was ultimately discovered by the resident's family, prompting a registered nurse to assess the wound and arrange for emergency care. Witness statements revealed that the LPN did not recall being informed of the injury, and there was a lack of timely follow-up and documentation as required by facility policy. In the second case, another resident with moderate cognitive impairment and a history of falls was observed with facial bruising and a hematoma by staff. The discoloration was reported to nurses at the station, but there was confusion among staff regarding who was responsible for assessing and reporting the injury. The assigned nurse did not document or report the injury, and no immediate assessment or notification to the medical provider occurred. The following day, the resident was found with more extensive bruising and swelling, at which point a full assessment was completed, and the resident was sent to the emergency room. Interviews with staff indicated that the initial report of the injury was not acted upon in a timely manner, and the required procedures for injuries of unknown origin were not followed. Both incidents demonstrate a failure to follow facility policy regarding timely assessment, documentation, and communication of changes in resident condition. Staff interviews revealed lapses in communication and uncertainty about responsibilities, resulting in delays in care and treatment for the affected residents. The deficiencies were identified through interviews, record reviews, and facility document reviews, which confirmed that the required interventions and notifications were not completed as specified in the facility's policies.