Failure to Immediately Notify Practitioner and Representative After Resident Injury
Penalty
Summary
The deficiency involves the facility’s failure to immediately consult with a resident’s physician and notify the resident’s representative after a change in condition related to new skin injuries. The resident was an elderly male with Parkinsonism, unspecified dementia with severe cognitive impairment (BIMS score 3/15), atherosclerosis, and heart disease, who required staff assistance with ADLs and had a care plan identifying fall risk and use of assist rails and a low bed. On the early morning in question, a CNA reported finding the resident with his forearms or hands tangled between the bed rail and mattress, noting skin tears on both elbows and bruising on the hands and forearms, and stated he immediately reported this to the male charge nurse (LVN B). The CNA documented that the resident was found between the bed rail and mattress and that he put the resident back in bed and reported it to the nurse. LVN B stated that around the same early morning time, the CNA only told him about bruises on the resident’s arms and did not report that the resident had been tangled or had a fall. LVN B reported that he assessed the resident and saw only bruises, applied moisturizer, and contacted the NP, who advised monitoring and did not order x‑rays because there was no reported fall. LVN B’s progress note documenting discolored areas to both arms and notification of the resident’s representative and NP was entered as a late entry approximately eight hours after he was first notified of the incident. The DON later stated that his expectation was that staff immediately report any incidents or changes to the NP and that LVN B did not enter progress notes in a timely manner. Subsequent observations and interviews showed that other staff became aware of the bruising later that morning. The UD learned of the bruises from the day‑shift charge nurse (LVN C), confirmed with the CNA that the resident had been found tangled in the assist rail, and observed unusual bruising on the resident’s hands while he was in the dining room. LVN C reported that when she came on duty and checked the electronic record, there were no night‑shift notes about the bruising, and she observed bruises worse than usual and reported them to administration. A wound assessment completed that afternoon by the treatment nurse documented two new non‑pressure skin tears/abrasions on the right hand and right elbow with an onset date matching the incident date, and notifications to the resident, representative, and physician were recorded at that time. The facility’s incident/accident policy and federal regulation at 42 CFR §483.10(g)(14)(i)(A) require immediate assessment and practitioner and representative notification after an accident involving injury with potential need for physician intervention, which was not done promptly in this case.
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