Failure to Monitor and Document Bruising and Skin Discoloration per Physician Orders
Penalty
Summary
The facility failed to monitor and document a resident’s left upper extremity bruising and anticoagulant-related bruising as ordered and per facility expectations. The resident, who had poor balance, iron deficiency anemia, and moderate cognitive impairment (BIMS score 10), was noted on a change in condition report dated December 16, 2025, after the resident’s son reported discoloration and a closed, dry skin tear on the left forearm. When questioned, the resident stated there had been no bruise until “she grabbed me, and then there was a bruise.” The physician recommended continued monitoring. The resident’s MAR for anticoagulant monitoring required staff to document “Y” if monitored with no issues or “N” if monitored and issues were observed, but from December 9–12 and December 14–17, 2025, nurses left the field blank and documented “--” instead of a Y or N response. The physician’s order summary and TAR for December 2025 directed staff to monitor the left upper extremity discoloration every shift for changes in size, location, and appearance and to notify the MD if changes were noted. However, the TAR showed no documentation of monitoring on multiple shifts, including specific night, afternoon, and morning shifts later in the month. Daily skilled charting from December 15–24, 2025, contained no additional notes describing the skin condition, and from December 16–20, 2025, there was no documented assessment of the newly identified left upper extremity bruise by licensed nurses. Weekly nursing summaries from December 16–23, 2025, also documented no skin changes or breakdown despite the new bruise identified on December 16. The care plan initiated for skin discoloration on December 16, 2025, referenced monitoring for emotional distress and checking the area of discoloration, but the record review and interviews with the RN and DON confirmed that required every-shift monitoring and documentation of the bruise and skin discoloration did not occur as ordered.
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