State Findings:
Based on interview, record review, and a review of the facility policy, it was determined the facility failed to immediately inform the physician and the responsible party when a change in condition occurred for one (1) of three (3) sampled residents (Resident #1). According to a staff member, purple bruising was observed from Resident #1’s left wrist down to his/her pinky finger (fifth digit) on 09/02/19. State Registered Nurse Aide (SRNA) #1 reported the change in Resident #1’s condition to Licensed Practical Nurse (LPN) #1 on 09/02/19. However, the facility failed to ensure Resident #1’s physician and responsible party were notified of the resident’s injury. The resident’s responsible party was not aware of the injury until 09/04/19, when she visited the resident and discovered the injury for herself. Further, the facility failed to notify the resident’s physician until the responsible party brought the injury to staff’s attention on 09/04/19, two days after the injury was initially discovered. Resident #1’s physician ordered an x-ray on 09/04/19 and determined that the resident had an acute non-displaced fracture of his/her fifth metacarpal (pinky finger) to his/her left hand.
Interview with the Director of Nursing (DON) on 09/13/19 at 3:40 PM revealed staff should have reported the bruising to Resident #1’s left hand immediately to her, the resident’s physician, and the resident’s representative on 09/02/19 as directed in the facility policy.
Interview with the Administrator on 09/13/19 at 4:30 PM revealed staff had been trained to report changes in the resident’s condition immediately as outlined in the facility policy. The Administrator also stated that LPN #1 should have reported Resident #1’s bruising to her, the resident’s representative, and the resident’s physician when the injury was identified on 09/02/19.
A post-survey interview with Physician #1 on 09/16/19 at 2:00 PM revealed he expected staff to follow their policy and procedures when changes in a resident’s condition were identified.
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