Failure to Identify and Treat Facial Swelling After Fall
Penalty
Summary
A deficiency occurred when the facility failed to identify and treat swelling on a resident's cheekbone following a fall, despite the swelling being observed by both a hospice nurse and a CNA. The resident, who had multiple complex diagnoses including severe cognitive impairment, dementia, diabetes, and psychiatric disorders, experienced two unwitnessed falls on the same day. After the first fall, the resident was assessed by the assigned LVN, who reported no injuries or swelling. However, later that day, the hospice nurse documented periorbital swelling to the left side of the resident's face and discussed it with facility staff. The hospice nurse also took a photograph of the swelling and noted it in her records, but no new physician orders were issued regarding the swelling, and there was no documentation of follow-up care for this condition by facility staff. Interviews revealed that the hospice nurse pointed out the swelling to a CNA during a transfer, but the CNA did not ensure that the nurse was made aware of the swelling, assuming the hospice nurse would report it. The assigned LVN and other CNAs stated they did not observe or were not informed of any swelling, and the swelling was not reported to the nurse by the CNA. The resident's family was not notified of the swelling until after the resident was transferred to the hospital following a second fall later that night. Facility documentation and interviews confirmed that the swelling was not addressed or treated by the facility prior to the resident's hospital transfer. The facility's policy required prompt notification of changes in a resident's condition, including injuries, to the physician and family. Despite this, the swelling observed after the first fall was not communicated or treated according to professional standards or the resident's care plan. The lack of timely identification and intervention for the facial swelling resulted in delayed treatment for the resident.