Failure to Complete Comprehensive Assessment After Abnormal X-Ray Findings
Penalty
Summary
The deficiency involves the facility’s failure to complete and document a comprehensive assessment for a resident who experienced a significant change in condition involving the left lower extremity. The resident was admitted with multiple serious diagnoses, including hemiplegia/hemiparesis after a cerebral infarction affecting the left side, a stage 4 pressure ulcer of the left ankle, type 2 diabetes mellitus, peripheral vascular disease, and anemia. The resident’s BIMS score indicated moderate cognitive impairment. On the morning of 2/8/26, a CNA notified nursing staff that the resident’s left foot appeared twisted. A nurse’s note documented that the left foot was in a twisted position, with a stage 4 wound, purple skin color, and skin cold to touch. A physician was contacted and a STAT x-ray of the left ankle, foot, and knee was ordered and carried out. Later that day, radiology results were reported to the facility, indicating a fracture and acute osteomyelitis of the distal lower leg. The clinical record shows that the physician was notified of the abnormal x-ray results in the early morning hours of 2/9/26. However, there is no documentation that the resident’s left leg and foot were reassessed for changes in condition or for pain after the initial assessment at approximately 11:00 AM on 2/8/26 and before or after the physician was notified of the x-ray findings. During interview, the nurse who received the handoff report acknowledged that although she and another nurse viewed the resident’s foot, she did not complete a comprehensive assessment at that time. The DON’s review of the x-ray results and nursing progress notes confirmed that the assigned RN should have completed and documented a comprehensive assessment using the SBAR Communication Form in response to the significant change in the resident’s condition. The DON stated that the assessment should have included a detailed description of the leg and foot, circulation status, presence of bleeding, necrosis, or further twisting, and whether the resident expressed pain or discomfort. The facility’s policy on change in a resident’s condition requires nurses to make detailed observations and gather relevant information, prompted by the Interact SBAR form, prior to notifying the physician. Job descriptions for LVNs, RNs, and the Nursing Supervisor also require assessment and observation of residents with changes in condition. Despite these requirements, a comprehensive reassessment was not completed or documented around the time the abnormal x-ray results were obtained and communicated, constituting the cited deficiency.
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