Failure to Identify and Document Forehead Abrasion of Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to identify, monitor, and respond to an injury of unknown origin on a resident’s forehead. The resident had chronic respiratory failure, schizophrenia, was nonverbal, rarely communicated, and was assessed as having severely impaired cognition, requiring total assistance for all ADLs and having no documented behaviors. The care plan directed staff to inspect the resident’s skin weekly and as needed, observing for redness, open areas, scratches, cuts, and bruises, and to report any changes to the nurse. Weekly skin notes for the period reviewed did not document any abrasion or bruise to the forehead. On the first day of the annual survey, the resident was observed in bed with a red abrasion on the right side of the forehead measuring approximately 0.5 cm by 2 cm. When asked if he had a fall, the resident shook his head side to side indicating no. The resident’s progress notes contained no evidence that staff had identified the forehead abrasion or investigated its origin until the following day, when a note documented a purple abrasion on the right forehead measuring 0.3 cm by 2.5 cm by 0 cm, with the resident unable to describe how it occurred. Staff reported no known event, and the note suggested the resident’s head may have hit the wall during cares after a recent room change that placed the bed against the wall, with a fall mat on the left side of the bed. A CNA who provided care reported she had not noticed the abrasion/redness and stated that any new skin issue should be reported to the nurse and that staff were required to write a statement for injuries such as bruises or skin tears. An LN reported being told by the night nurse that the resident had an abrasion but did not document it, assuming the night nurse had done so. An administrative nurse stated she was not aware of the abrasion and that the nurse should have reported, assessed, and completed risk management and a root cause analysis for the abrasion.
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