Failure to Immediately Notify Family of Resident Injury
Penalty
Summary
The facility failed to immediately notify a resident's representative when an injury was identified. The resident, who had chronic lymphocytic leukemia, chronic kidney disease, and severe cognitive impairment, was found to have significant bruising on her chest by a registered nurse. The nurse observed the bruise on the resident's chest, described its size and color, and noted that the resident often clasped her hands tightly against her chest, which was consistent with the location of the bruising. The Director of Nursing (DON) was notified of the bruising and conducted an assessment, determining that the bruising was likely due to the resident's own actions and her medical condition, which made her prone to bruising. The findings were discussed in a staff meeting, but the DON became ill and left work before a report was initiated. The facility's documentation indicated that the bruising was not reported to the resident's family until several days after it was first observed. The family was only informed after the bruise was already in the process of healing, and the delay in notification was confirmed by both the family and the facility's administrator. The administrator acknowledged that the family was upset about not being contacted promptly when the bruising was discovered. The deficiency centers on the facility's failure to immediately notify the resident's representative of the injury as required.