Failure to Timely Assess Extensive Bruising and Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assessment and care for a significant bruise on a resident’s right inner/outer thigh and hip area after staff became aware of it. The resident had moderate cognitive impairment with a BIMS score of 11, could understand and be understood by others, and had diagnoses including hypertension, Alzheimer’s disease, anxiety, depression, low back pain, and a history of falls. The resident required total assistance with toileting and substantial to maximal assistance with hygiene and dressing, and had a care plan focus for risk of skin breakdown with interventions including observation of skin with cares and notification of the nurse or provider of concerns. On 2/13/26, CNAs reported noticing purple/green swelling and bruising on the resident’s right hip and under the buttocks, described as noticeable, and another CNA reported it took two staff and a gait belt to transfer the resident and that they noticed a bruise while in the bathroom. On 2/14/26, a CNA stated they told the nurse about the bruises at 8:45 AM, but the LPN later admitted they did not look at the bruise that day, stating it slipped their mind. During this period, the resident reportedly did not show signs of pain on 2/14/26, and no nursing assessment of the bruised area was documented until the following day. On 2/15/26 at 10:40 AM, staff called the nurse to the resident’s bathroom due to the resident’s discomfort when transferring from the toilet to the wheelchair, and a large dark purple bruise was observed extending from the right upper inner thigh to the buttock, with various colors including purple, brownish, and faded yellow, and faint yellow bruising on the left thigh. Later that day, the resident was observed in bed with the right leg appearing shorter than the left, the right knee turned outward, non-pitting edema of the thigh and knee, and pain with gentle passive range of motion. Facility documentation, including a risk management form, health status note, incident notes, and an investigation file, consistently described the extensive bruising and the resident’s pain with movement, and administrative staff acknowledged that the nurse failed to assess the bruise when first alerted on 2/14/26, contrary to expectations and the facility’s skin program, which required use of risk management for identification of skin issues and follow-up observation.
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