Failure to Monitor and Document Care After Resident Tongue Laceration
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate monitoring and documentation of care for a resident who sustained a tongue injury. The resident was admitted with metabolic encephalopathy, morbid obesity, and paroxysmal atrial fibrillation, and was taking a blood thinner. An MDS dated 10/29/25 showed the resident had an intact BIMS score of 15/15. On 12/3/25 at 9:40 p.m., an LVN noted blood in the resident’s mouth, and the resident reported he had bitten his tongue. An SBAR form documented that the resident refused transfer to the hospital and that the MD’s recommendation was to continue monitoring. The facility’s Acute Condition Changes – Clinical Protocol required staff to monitor and document the resident’s progress and responses to treatment so the physician could adjust treatment accordingly. During interview, the LVN stated the resident was monitored every 15 minutes after the bleeding was noted but could not recall the resident’s condition at each check and did not remember documenting these assessments. The night-shift RN reported that the resident’s tongue continued to bleed through the night, but the RN did not know how much bleeding occurred, and although pressure was applied to the tongue, the RN was unsure whether monitoring and interventions were documented. Review of the resident’s progress notes from the evening of 12/3/25 through the early morning of 12/4/25 showed no documentation that the LVN or RN monitored the resident or provided interventions during that period. A subsequent SBAR form on 12/4/25 indicated the resident continued to bleed through the night, and the RN notified the MD of prolonged bleeding at 6:21 a.m., at which time EMS was called and the resident was sent to the hospital, where the tongue laceration required multiple methods to control significant bleeding related to blood thinner use.
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