The incomplete assessment at Avon Place Healthcare Center violated basic nursing protocols for evaluating injuries of unknown origin, federal inspectors found during a November complaint investigation.
Resident #77, who has cognitive impairment, was found with bruising on her hand. Registered Nurse #302 examined only the visible areas of the resident's skin after being notified of the injury.
"RN #302 revealed she had not removed the resident's gown to assess the resident's skin had not check the resident's range of motion for additional injuries," inspectors wrote.
The resident had told nursing assistants she was concerned about her leg. But that information never reached the nurse conducting the assessment.
Certified Nursing Assistant #306 acknowledged the nurse should have been notified before getting the resident out of bed. The assistant also revealed the resident's leg complaint was never reported to nursing staff.
When inspectors interviewed RN #302 on November 18, she confirmed she had looked only at the resident's hand and other visible skin areas. She had not performed the comprehensive evaluation required when residents present with unexplained injuries.
Licensed Practical Nurse #402 explained the proper protocol to inspectors. When a resident has an injury, staff should ask how it occurred and question staff who last worked with the resident.
"The resident should have a complete head to toe assessment to check for additional injuries," LPN #402 told inspectors. Range of motion should be assessed if safe to do so, and the physician should be notified.
The facility's own policy supports this approach. The Protocol for Focused Nursing Assessment states that such evaluations should identify immediate needs, monitor changes, and evaluate intervention effectiveness during acute changes in a patient's condition.
But the policy contains no specific guidelines for assessing range of motion or checking for additional injuries when cognitively impaired residents are found with bruising of unknown origin.
Director of Nursing staff defended the incomplete assessment during interviews. She told inspectors that nurses can assess residents while they move in bed and don't necessarily need to include range of motion testing.
The DON said she believed the nurse had properly assessed the resident, notified the physician, and implemented new orders. Based on the initial assessment, she didn't think range of motion testing was necessary.
However, the DON acknowledged that if a resident complains of pain in other areas, a head-to-toe assessment should be completed.
The case highlights gaps in injury assessment protocols for vulnerable residents who cannot clearly communicate how injuries occurred. Cognitively impaired residents may be unable to accurately describe when, where, or how they were hurt.
Federal inspectors found the facility's response fell short of accepted nursing standards. The incomplete assessment meant potential injuries to the resident's leg were never evaluated, despite her expressed concerns.
The violation was classified as causing minimal harm or potential for actual harm, affecting few residents. But it represents a systemic failure in the facility's injury assessment procedures.
Resident #77's case demonstrates how communication breakdowns between nursing assistants and registered nurses can leave injuries undetected. The nursing assistant knew about the leg complaint but never passed that critical information to the RN conducting the assessment.
The facility's policy requires focused assessments during acute changes but provides no clear guidance for the specific situation staff encountered. This policy gap may have contributed to the inadequate response.
Without a complete evaluation, the facility cannot determine whether the resident sustained additional injuries beyond the visible hand bruising. The leg pain she reported to nursing assistants remains uninvestigated.
The inspection occurred as part of a complaint investigation, suggesting someone raised concerns about the facility's injury assessment practices. Federal regulators found those concerns were justified.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avon Place Healthcare Center from 2025-11-18 including all violations, facility responses, and corrective action plans.