SANTA MONICA, CA - A nursing home inspection revealed significant delays in reporting and documenting a resident's unexplained facial injuries, with staff waiting over three days to notify medical personnel and administrators about bruising that required emergency medical evaluation.
Delayed Discovery and Reporting of Facial Injuries
The Rehabilitation Center of Santa Monica came under scrutiny during an August 2024 inspection when investigators discovered serious gaps in the facility's injury reporting protocols. The case centered on an 84-year-old resident with dementia and multiple medical conditions who developed unexplained bruising to the forehead and left cheek.
Multiple staff members observed the injuries between August 2-4, 2024, but failed to follow proper reporting procedures. A Certified Nursing Assistant first noticed blue and purple discoloration on the resident's forehead on August 2nd during the night shift but did not report the findings. The aide later explained, "in my own assumption, in my knowledge, it was reported. I just thought it was there before, so I didn't report it."
The injuries became more apparent over the following days, with staff describing maroon, reddish, purple, light yellow, and dark red discoloration on the resident's forehead along with swelling, plus additional bruising on the left cheek. When inspectors observed the resident on August 5th, they noted facial grimacing and the resident pointing to their forehead when asked about pain, though the resident could not communicate a pain level.
Medical Documentation and Response Failures
The facility's response to the resident's injuries revealed multiple systemic failures in medical documentation and care coordination. Despite the severity of the visible injuries, the facility's medical chart contained no nursing progress notes, physician orders, skin assessments, medication administration records, or incident reports related to the injuries.
The attending physician was not notified until August 5th at 11 AM - more than three days after the injuries were first observed. When questioned about the delay, the registered nurse on duty stated, "I got busy." This delay occurred despite the resident's compromised medical status, including being on Eliquis, a blood thinner that can increase bruising and bleeding risks.
The medical response, when it finally occurred, was appropriate. The physician ordered a CT scan of the head due to concerns about potential head injury. The scan, performed on August 6th, revealed chronic brain changes but ruled out acute head trauma. However, the delay in medical evaluation could have had serious consequences given the resident's medical vulnerabilities.
Impact of Blood Thinners on Injury Assessment
The resident's use of Eliquis, a blood-thinning medication, made the delayed reporting particularly concerning from a medical standpoint. Blood thinners significantly increase the risk of serious bleeding and bruising complications, making prompt medical evaluation of any unexplained injuries critical.
When individuals on blood thinners develop unexplained bruising, healthcare providers must quickly assess whether the injuries indicate internal bleeding, medication dosage issues, or potential trauma. The three-day delay in this case meant that crucial assessment time was lost, during which the resident's condition could have deteriorated if internal bleeding had been present.
Standard medical protocols require immediate physician notification when patients on anticoagulants develop new or unexplained injuries. The facility eventually placed the resident on a care plan that included pain assessment every shift, monitoring for neurological changes, vital sign checks, and skin breakdown monitoring for 14 days.
Communication Breakdown Among Staff
The inspection revealed a troubling pattern of communication failures among different levels of nursing staff. Licensed Vocational Nurses observed the injuries on multiple occasions but failed to escalate concerns appropriately. One LVN who noticed the injuries on August 2nd stated they "assumed the SBAR/COC was already completed" but wasn't sure if administrators had been notified.
Another LVN who was informed about the injuries on August 4th acknowledged the reporting failures, stating "I should have notified [the physician] about Resident 4's bruises on the forehead and left cheek." This staff member also admitted to not completing proper documentation or notifying supervisors, explaining they were "passing medications" and the resident "was not complaining of pain."
The facility's own job descriptions clearly outlined staff responsibilities that were not followed. CNAs are required to "recognize abnormal changes in body functioning and importance of reporting such changes to a supervisor" and "observe resident's skin when giving care and reports changes to any licensed nurses." LVNs must "communicate with physicians regarding changes in resident's condition" and complete required documentation in accordance with regulations.
Family Notification Delays
The resident's family members were not promptly informed about the injuries, creating additional concerns about transparency and communication. Family members discovered the bruising during a routine visit on either August 1st or 2nd, before the facility had notified them. When family members asked nursing staff about the injuries, they were told the staff didn't know how the bruising occurred.
The family finally received official notification from the facility on August 5th, after they had already observed the injuries themselves and raised questions. This delayed communication violated the trust between families and the facility, particularly important for residents with dementia who cannot advocate for themselves.
Investigation Response and Administrative Oversight
The facility's investigation into the incident revealed additional concerns about administrative oversight. The Administrator stated that an investigation began on August 5th and indicated that reports to state authorities, the Ombudsman, and law enforcement would only be made if their internal investigation concluded the resident had been allegedly abused.
This approach raises questions about the facility's understanding of mandatory reporting requirements. State regulations typically require immediate reporting of injuries of unknown origin, regardless of the facility's internal conclusions about potential abuse. The three-day delay in initial reporting meant that crucial evidence and witness accounts may have been compromised.
The Director of Nursing was unable to provide skin assessments for the resident covering the months of April through August 2024, suggesting broader documentation deficiencies beyond this specific incident.
Additional Issues Identified
The inspection also revealed other operational concerns at the facility. The nursing home was in transition from paper charting to electronic systems, with physician orders handled electronically while other documentation remained on paper. This hybrid system may have contributed to communication and documentation gaps.
Staff training appeared inadequate, as multiple employees demonstrated poor understanding of reporting requirements and the potential consequences of delayed reporting. Several staff members could not explain what might happen if injuries weren't properly reported or documented.
The Medical Records Director was unable to locate required skin assessment documentation, indicating potential issues with record-keeping and organization that extended beyond this single incident.
Medical Standards and Best Practices
Healthcare facilities are required to maintain comprehensive monitoring systems for residents, particularly those with cognitive impairment who cannot report injuries or abuse themselves. Standard protocols require immediate physician notification for unexplained injuries, especially in residents taking medications that increase bleeding risks.
Proper skin assessment documentation should occur regularly and be readily accessible for review. When injuries of unknown origin are discovered, facilities must initiate immediate medical evaluation, family notification, and regulatory reporting while preserving evidence for potential investigations.
The case highlights the critical importance of staff training on recognition and reporting procedures, particularly for facilities serving vulnerable populations with dementia and other cognitive impairments who depend entirely on staff advocacy for their safety and medical care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Rehabilitation Center of Santa Monica from 2024-08-08 including all violations, facility responses, and corrective action plans.
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