Failure to Notify Provider of New Bruise of Unknown Origin
Penalty
Summary
Nursing staff failed to notify the provider when a cognitively impaired resident, who was dependent on staff for care, was observed with a new bruise of unknown origin near the right eye. The facility's policy required that the physician be notified of any unexpected or substantial change in a resident's condition, including new injuries. Despite this, when the bruise was discovered by a nurse during morning rounds, the nurse only notified the Unit Manager and completed internal incident documentation, but did not contact the physician or the Director of Nursing as required. The Unit Manager, after being informed by the nurse, assessed the bruise and instructed the nurse to complete the necessary incident and skin/bruise reports, but also did not notify the provider or the Director of Nursing. Documentation in the resident's progress notes over several days confirmed the presence of the bruise, but there was no evidence that the provider was informed at any point during this period. The resident, who had diagnoses including vascular dementia, osteoporosis, and a history of stroke, was unable to communicate how the injury occurred. Subsequently, the resident was transferred to the hospital for evaluation of altered mental status and self-removal of a urinary catheter. At the hospital, imaging revealed a right temporal bone fracture and subarachnoid hemorrhage, with no reported trauma. The provider confirmed during an interview that they had not been notified of the bruise and stated that such notification was necessary, as it could have warranted immediate evaluation. The Director of Nursing also acknowledged that the required notifications had not been made when the bruise was first observed.