Failure to Assess and Document Resident Skin Bruise
Penalty
Summary
The facility failed to ensure timely assessment, identification, and documentation of a change in skin condition for one resident. Facility policy on Skin Integrity and Wound Management required nursing assistants to observe skin daily and report changes to a nurse, and required licensed nurses to evaluate reported or suspected skin changes, document newly identified skin impairments as a change in condition, record findings on the 24-hour report, and perform and document skin inspections on all newly admitted or readmitted residents and weekly thereafter or with any significant change. The resident involved had diagnoses including brain neoplasm, epilepsy, and cortical blindness, and a recent MDS showed a BIMS score of 3, indicating severe cognitive impairment. The resident was transferred to the hospital and then readmitted; the readmission skin assessment documented no bruise on the right inner forearm. The resident’s clinical record showed weekly skin assessments and wound care treatments on multiple dates, and a physician’s order directed application of a geri sleeve to the left arm with removal for skin checks, treatment, and hygiene. During an interview, a family member reported the resident had an unexplained bruise on the right inner forearm. On observation with the DON present, the resident was noted to be wearing geri sleeves on both arms, and the DON’s skin assessment at that time identified a fading bruise on the right lower inner forearm. The DON confirmed there was no documentation in the clinical record identifying this bruise, indicating that the change in skin condition had not been assessed and documented as required by facility policy and regulatory standards.
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