Failure to Notify Nurse of Resident Laceration Following Transfer
Penalty
Summary
A Certified Nursing Assistant (CNA) failed to notify a nurse after discovering a laceration on a resident's leg, which constituted a change in the resident's condition. The resident, who had multiple diagnoses including metabolic encephalopathy, gastrointestinal hemorrhage, and bullous pemphigoid, was dependent for transfers and toileting. The incident began when the CNA observed the resident's leg was bleeding, covered the wound with a towel, and proceeded to assist the resident with toileting. The CNA did not immediately inform the nurse about the injury, stating later that she became distracted by answering other call lights and forgot to report the incident. The deficiency was identified when another CNA responded to the resident's call light and noticed the laceration, prompting nurse intervention. Documentation showed that the resident was later sent to the emergency room, where she received nine stitches for the deep laceration. Interviews with facility staff, including the Director of Nursing (DON) and the Administrator, confirmed that the CNA had not reported the injury as required by facility policy, which mandates prompt notification of changes in resident condition, including injuries that may require physician intervention. Further investigation, including review of facility camera footage and staff interviews, indicated that the injury likely occurred during a transfer performed by the CNA. The CNA admitted to covering the wound and not reporting it immediately due to fear of getting in trouble and being distracted by other duties. The failure to promptly notify nursing staff delayed appropriate assessment and intervention for the resident's injury.