Failure to Update Care Plan and Provide Adequate Supervision for Resident with Recurrent Bruising
Penalty
Summary
A deficiency was identified when the facility failed to provide adequate supervision and develop new care plan interventions to prevent injury and bruising for a resident with a known history of injury and bruising. The resident, who has multiple diagnoses including Parkinson's disease, atrial fibrillation (on anticoagulant therapy), dementia, and behavioral issues such as agitation and resistance to care, was observed with fading bruises on her right hand and forearm. Staff interviews revealed that the resident is prone to swinging her arms and hitting hard objects during episodes of agitation, which, combined with her blood thinning medication, increases her risk for bruising. Despite this, protective devices such as Geri sleeves or padded side rails were not consistently used, and staff acknowledged that interventions to prevent further injury were not implemented. Family members repeatedly raised concerns about the resident's bruising, suspecting abuse, and reported these concerns to the state health department. The facility's administrator and staff confirmed that incidents of unexplained bruising had occurred previously, and that the care plan had not been updated to address these recurring injuries. There was no documentation of new interventions or interdisciplinary team meetings to address the resident's ongoing risk for injury, nor was there evidence of regular skin assessments as required by the care plan for residents on anticoagulants. Additionally, the facility lacked a specific policy on resident safety and prevention of injury. Record review further showed that abuse/neglect assessments were not completed after each incident or allegation, and refusals of assessment by the resident or family were not documented. The last care plan conference with the family occurred months prior, and there was no follow-up after multiple allegations of abuse. The facility's own policies require ongoing assessment and care plan revision as resident conditions change, but these were not followed in this case, resulting in a failure to ensure adequate supervision and protection from injury for the resident.