Failure to Assess, Document, and Notify Provider of Resident Injury
Penalty
Summary
The facility failed to assess, document, notify the provider, and monitor an injury of unknown origin for a resident with severe cognitive impairment and significant physical dependencies. The resident, who had a history of stroke with left-sided weakness and required total assistance for activities of daily living, was observed by staff to have a large bruise on her left upper arm. Multiple CNAs and nurses noticed the bruise, which was initially red and later turned yellow, but there was no documentation or assessment of the bruise in the medical record prior to several days after it was first observed. Staff interviews revealed that the bruise was reported to nurses, but the nurses either assumed it was old or did not take further action, and there was no immediate notification to the provider or documentation of the injury. The resident exhibited pain with movement of her left arm, which was noted by staff during care, but this pain was not promptly reported or documented. It was only after several days, when the unit manager was made aware of the bruise, that the nurse contacted the provider and an X-ray was ordered. The X-ray revealed a non-displaced fracture of the left humerus. The facility's policies required prompt assessment, documentation, and provider notification for new skin issues or injuries of unknown origin, but these procedures were not followed in this case. The investigation found that the lack of timely assessment and documentation led to a delay in diagnosing the resident's fracture. Staff interviews confirmed that the bruise and associated pain were observed and reported among staff, but not properly escalated or recorded. The provider was not notified until three days after the initial observation of the bruise and pain, resulting in a delay in obtaining appropriate medical orders and treatment for the resident's injury.