Failure to Timely Assess and Document Reported Arm Bruise
Penalty
Summary
The deficiency involves the facility’s failure to assess and document a newly observed bruise on a resident’s right arm in a timely manner after it was reported to nursing staff. The resident had been admitted with diagnoses including heart failure, hypertension, and type 2 diabetes mellitus. During an unannounced visit on December 2, 2025, surveyors reviewed records and conducted interviews. CNA 1, who worked the evening shift on November 17, 2025, reported that she observed a bruise on the resident’s right forearm and notified a licensed nurse, but she did not know what occurred afterward. CNA 2 also reported that she notified LVN 1 of an olive-toned bruise on the resident’s right arm on November 17, 2025, and stated she did not see LVN 1 assess the resident’s arm. LVN 1 confirmed that a CNA had informed her on November 17, at about 7 a.m., that the resident had a bruise, but she did not assess or document the bruise, stating she believed it was old and related to a previous fall. A review of the resident’s progress notes showed no documentation of an assessment of the right arm bruise on November 17, 2025, despite it being observed and reported that day. The first documented assessment appeared in a progress note dated November 18, 2025, at 9:53 a.m., which stated that the writer noticed the resident’s right arm had a purplish discoloration and notified the treatment nurse. The DON stated that the licensed nurse who was notified of the bruise did not follow the facility’s policy and procedure for evaluation and notification of a change in condition.
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