Failure to Timely Assess and Intervene for Resident Bleeding from Skin Tears
Penalty
Summary
A licensed vocational nurse (LVN) failed to assess and perform necessary interventions to stop a resident from bleeding due to skin tears. The resident, an elderly female with Alzheimer's disease, muscle weakness, chronic pain, hypertension, and a history of impaired skin integrity, developed new skin tears on her lower leg that resulted in significant bleeding. The resident was known to have very fragile skin, exacerbated by long-term prednisone use and bilateral leg edema, making her prone to skin injuries. On the morning of the incident, certified nursing assistants (CNAs) discovered the resident bleeding from newly developed skin tears while providing care. The CNAs reported the bleeding to the LVN, who was administering medications at the time. The LVN stated she was busy and would attend to the resident after completing her medication pass. The CNAs attempted to control the bleeding by wrapping a towel around the wound, but the LVN did not assess or intervene before the end of her shift. The LVN later contacted one of the CNAs at home to inquire about the severity of the wound, admitting she had forgotten to address the bleeding. The resident continued to bleed until the next shift, when a registered nurse (RN) was notified and promptly intervened to control the bleeding. The RN found the resident with multiple skin tears and significant blood loss, requiring several bandage changes to contain the bleeding. There was no handover or report given to the oncoming staff regarding the resident's condition, and the incident was only discovered during a routine check at the start of the day shift.