Failure to Timely Assess and Monitor Resident After Unwitnessed Injury
Penalty
Summary
A deficiency occurred when nursing staff failed to conduct a comprehensive nursing assessment and timely neurological assessments after a nurse aide reported newly identified facial bruising on a resident following an unwitnessed injury. The resident, who had a history of terminal cancer, dementia, previous falls, and was on anticoagulant therapy, was found with significant bruising to the right side of the face, right shoulder, both knees, left toe, and a reddened area on the left neck. Despite the nurse aide's report of new marks at approximately 5:00 AM, the assigned nurse did not immediately assess the resident or investigate the cause of the injuries. The nurse on duty during the night shift observed red marks on the resident's face during medication administration but did not perform a full assessment or follow up when the nurse aide later reported additional bruising. The nurse assumed the marks had already been addressed by the previous shift and did not communicate any concerns during shift change. The resident was not thoroughly assessed until several hours later by the day shift nurse, who then identified multiple areas of bruising and notified the appropriate clinical leadership and physician. Documentation revealed that neurological assessments were not performed promptly or consistently with up-to-date vital signs following the discovery of the injuries. Some neurological assessments were recorded with outdated vital signs, and there was confusion among staff regarding the facility's protocol for neurological monitoring after unwitnessed injuries. The delay in assessment and incomplete documentation contributed to the deficiency in providing appropriate and timely care for the resident after the injury was identified.