Failure to Timely Report and Assess Resident Head Injury
Penalty
Summary
Facility staff failed to provide care consistent with professional standards when they did not immediately report a large bruise and abrasion to a resident's head, resulting in delayed assessment, care, and required notifications to the family and physician. The resident, who had diagnoses including Alzheimer's disease and osteoporosis, was found with a significant knot and bruising on the forehead, as well as a small cut. The incident was first noticed by a hospice worker, who observed dried blood on the resident's pillow and bed rail, and subsequently reported it to nursing staff. Upon assessment, the nurse practitioner and family were notified, but this occurred only after the hospice worker's intervention. Review of documentation and staff interviews revealed that a CNA had been feeding the resident the previous day when the resident overturned a tray onto themselves. The CNA cleaned the resident and the room but did not report the incident, believing it was not significant. The following morning, the same CNA noticed the injury but again did not report it, assuming someone else had already done so. There was no documentation of the incident or injury in the medical record prior to the hospice worker's report, and no vital signs or neurological checks were recorded during the critical period following the injury. Interviews with nursing staff and facility leadership confirmed that the injury was not communicated during shift change, and no assessments or documentation were completed until after the hospice worker's report. The Director of Nursing and Administrator both stated that staff are expected to report all injuries immediately and document them, but this did not occur in this case, resulting in a delay in assessment and care for the resident.