Failure to Assess and Monitor Resident with Change in Condition and Bruising
Penalty
Summary
The facility failed to adequately assess and monitor a resident who exhibited significant skin discoloration and a potential change in condition. The resident, who had a history of dementia and a left hip contracture, was observed by staff to have extensive bruising on her arm, breast, and back, with colors ranging from yellow to dark purple. Multiple staff members noted that the resident was not responding as usual and appeared to have a change in mentation, but there was a lack of thorough assessment and documentation by nursing staff. The nurse on duty did not enter the resident's room for a direct assessment when first notified of the bruising and relied on the CNA to check for warmth under the arm, rather than performing a comprehensive evaluation. There was no documentation of a full skin assessment or monitoring of the resident's condition between the time the bruising was first reported and when the resident was eventually sent to the hospital several hours later. The only progress note written by the nurse reflected what the CNA reported, without any detailed description of the bruising's size, color, or the resident's pain level. Additionally, there was no documentation of vital signs or other monitoring during this period, and the last recorded vital signs were taken approximately nine hours before the hospital transfer. Further review revealed that no skin observation assessments were documented for the resident for a period of 25 days, despite staff having observed bruising prior to the incident and not reporting it. Interviews with the DON and ADON indicated a lack of awareness regarding the absence of assessments and monitoring, and there was inconsistency in staff understanding of the protocol for assessing and documenting changes in condition. The deficiency centers on the facility's failure to provide appropriate assessment, documentation, and monitoring in response to a resident's change in condition and visible injuries.