Failure to Report Skin Irregularities Observed by Nurse Aide
Penalty
Summary
A nurse aide failed to follow facility procedures when she observed three brown and yellow skin irregularities on a resident's left forearm during morning care. The aide did not notify the charge nurse or other nursing leadership, as required by facility policy, because she did not consider the irregularities to be suspicious or serious. The aide had previously received training on reporting abnormal findings but did not act in accordance with this training. The resident involved was an elderly female with multiple diagnoses, including severe protein calorie malnutrition, dementia, and recent digestive system surgery. Her care plan identified her as being at risk for pressure ulcers and required staff to notify nursing leadership immediately of any new skin breakdown, including discoloration, blisters, or bruises. Prior weekly skin assessments and progress notes did not document any skin irregularities, and there was no record of the aide's observation in the resident's medical record. Upon later observation by surveyors, five skin irregularities were found on the resident's left forearm, including areas of red and dark purple discoloration. The resident was unable to recall the origin of the marks and did not report pain or distress. The Director of Nursing confirmed that the aide should have reported the findings immediately, as per facility policy, to allow for timely assessment and documentation by nursing staff.