Failure to Accurately Assess Resident for Additional Injuries After Unexplained Bruising
Penalty
Summary
A deficiency occurred when staff failed to accurately assess a resident for additional injuries after the discovery of unexplained bruising. The resident, who had severe cognitive impairment due to dementia and multiple comorbidities including osteoporosis and atrial fibrillation, was observed on surveillance video with visible bruising on the right hand during incontinence care. Later, while being assisted out of bed, the resident verbalized leg pain, but this concern was not acknowledged or reported by the CNAs present. Documentation showed that only the bruised hand was noted, and no comprehensive assessment for other injuries or range of motion was performed at that time. Subsequent hospital records revealed that the resident had sustained fractures to the right hand and possibly the left hip, with imaging recommended to further assess the hip. Interviews with staff confirmed that a full head-to-toe assessment and range of motion evaluation were not completed after the initial discovery of the injury. The nurse and CNA involved did not remove the resident's gown to check for additional injuries, nor did they respond to the resident's complaint of leg pain. The facility's policy on focused nursing assessment did not provide specific guidance for assessing range of motion or additional injuries in cognitively impaired residents with unexplained bruising. Staff interviews indicated a lack of consistent practice in assessing residents with injuries of unknown origin, particularly in residents with cognitive impairment who may not be able to clearly communicate their symptoms. The deficiency was further evidenced by the absence of documentation regarding a thorough assessment and the failure to identify additional injuries until after hospital evaluation.