Failure to Identify, Assess, and Document Unexplained Bruising
Penalty
Summary
Staff failed to identify, assess, investigate, and document bruising of unknown origin for a resident with significant medical history, including cerebral infarction, hemiplegia, hemiparesis, muscle weakness, cognitive communication deficit, dementia, anxiety disorder, and aphasia. Upon admission and during initial assessments, no new skin issues were noted, but subsequent observations revealed scattered bruising, particularly on the right arm, and later, significant bruising on the resident's forehead and left ring finger. The bruising was not present prior to admission, according to the resident's family, and was first noticed by family members and staff on different occasions. Multiple staff members, including CNAs and LPNs, observed the bruising at various times but failed to consistently report, assess, or document the findings as required by facility policy. Some CNAs did not report the bruising to nurses, assuming it was either pre-existing or that the nurse was already aware. LPNs who noticed the bruising did not always assess or document it, and in some cases, did not consider the bruising significant enough to warrant further action. There was also a lack of communication between shifts, with no documentation or handoff information regarding the bruising. Facility policy required thorough investigation and documentation of all marks, discolorations, and injuries of unknown origin, including assessment, notification of the DON and physician, and completion of an event report. However, these procedures were not followed for the resident's bruising. The care plan did not address the bruising, and there was no evidence of a timely or comprehensive investigation into the cause of the injuries. Interviews with staff and administration confirmed that the required steps for assessment, documentation, and reporting were not consistently implemented.