F0658

D

Failure to Re-Assess and Monitor Ongoing Forearm Bruise

Porterville, California Survey Completed on 02-09-2026

Penalty

No penalty information released

Summary

The facility failed to ensure services met professional standards of quality when nursing staff did not re-assess and monitor a resident’s right forearm bruise after the initial monitoring period ended. The resident was admitted with discoloration (bruising) to both forearms, and a skin re-assessment the following day documented a right forearm bruise measuring approximately 6 cm by 5 cm. The treatment record for the month showed that the bruise was monitored only until a monitoring order was completed on 1/23/26, after which no further re-assessments were documented, despite the bruise still being present. During interview and concurrent record review, the treatment nurse confirmed the resident had been admitted with the right forearm bruise, acknowledged that facility practice was to re-assess skin bruises after completion of the monitoring order to ensure they were not new or worsening, and verified that the bruise remained present but was not re-assessed as required. Review of the facility’s undated Skin Assessment policy indicated that a full body, head-to-toe skin assessment was to be conducted on admission/re-admission, daily for three days, and weekly thereafter, which was not followed for this resident’s ongoing bruise.