F0842

D

Failure to Document New Skin Discoloration and Related Clinical Actions

Chicago, Illinois Survey Completed on 01-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain an accurate and complete medical record for a resident who developed new skin discoloration/bruising on the left side of the body. A CNA reported that during a scheduled shower she observed new discoloration/bruising on the resident’s left side and immediately notified the LPN and documented her observation in her own CNA charting. The CNA stated she had not witnessed any fall or injury and that this was the first time she saw the bruise. The resident’s face sheet shows multiple diagnoses, including type 2 diabetes mellitus with diabetic polyneuropathy, dementia, and a stage 3 sacral pressure ulcer.

The LPN confirmed being notified by the CNA after lunch and described seeing a bruise on the resident’s left side, below the armpit and next to the breast. The LPN stated she asked the DON to assess the resident, and after approximately 20 minutes the DON instructed her to order a stat X-ray. The LPN reported that the resident is on long-term blood thinner medication, tends to lean to the left side, and requires frequent repositioning, and that she notified the physician of the negative X-ray results. However, the LPN acknowledged that she did not document the bruising/discoloration, the assessment, the notification to the physician, or the interventions in the resident’s electronic health record, stating she was waiting for direction from the DON. The radiology note only documented that X-ray results were relayed to the physician with no new orders, and there was no documentation in the medical record regarding the new skin discoloration or the change in condition, despite facility policy requiring documentation and physician notification for any new skin discoloration.