Failure to Monitor, Assess, and Document Bruising and Delayed Diagnostic Orders
Penalty
Summary
Facility staff failed to provide care according to standards of practice for a resident with multiple diagnoses, including congestive heart failure, high blood pressure, expressive aphasia, and depression. The resident, who had moderate cognitive impairment and was independent with activities of daily living, reported a large, painful bruise on the left lower leg. The nurse observed a significant hematoma and bruising but did not immediately determine the cause, question staff about possible injury or falls, or complete a skin assessment at the time of discovery. The nurse notified the DON, physician, and family, but there was a delay in obtaining and documenting physician orders for diagnostic tests. Physician orders for an extremity ultrasound and a tibia/fibula x-ray were not obtained until three days after the bruise was discovered. There was also a delay in completing the ordered tests due to an error in the order and equipment brought by the technician. Staff failed to document the process and results related to the ultrasound and x-ray in the resident's progress notes. Additionally, there was no documentation of a fall on the date the bruise was discovered, and staff did not consistently monitor or document the resident's condition or the status of the bruise in subsequent progress notes and skin assessments. Interviews with nursing staff and the DON confirmed that the nurse should have completed a skin assessment upon discovery of the bruise, monitored the bruise every shift, and documented all notifications and results. The DON was unaware of the delay in entering the diagnostic orders and noted that the nurse incorrectly documented a fall. The facility's policy required prompt notification and documentation of changes in condition, but these procedures were not followed, resulting in a lack of timely assessment, monitoring, and documentation for the resident's injury.