Failure to Assess and Document Large Back Bruise and Notify Family
Penalty
Summary
The deficiency involves the facility’s failure to complete a thorough and accurate assessment of a large bruised area on a resident’s back and to document ongoing evaluation of the condition. Hospital documentation dated 1/21/26 indicated that the resident had a traumatic wound on admission to the right side of the back measuring 22 cm by 9 cm, described as purple and red with erythema. The resident’s diagnoses included stroke, and the clinical record did not indicate that the resident had a fall. A progress note dated 12/21/25 at 2:23 p.m. documented that dark areas on the resident’s back had worsened, were getting darker, and increasing in size, and that an event was opened to ensure the wound nurse was aware and the Nurse Practitioner was notified. However, there were no further assessments of the back area documented after this note. Review of the wound management record on 1/28/26 showed no bruising assessment for the resident’s back or any other assessment of the back. During interview, the DNS stated that when an event was created in the computer it was turned into an internal incident report, and no additional documentation or assessments were provided to surveyors. The facility’s bruising policy required completion of a bruise incident in the electronic health record along with a template/assessment progress note, but such documentation was not present. In addition, during an interview, the resident’s family member reported they were not notified of a large bruise on the resident’s back. The resident reported having had a fall during a transfer with staff and hitting the side of the bed, and the family member was not aware of either the fall or the bruising.
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