Failure to Timely Notify Physician After Resident Fall
Penalty
Summary
The facility failed to provide care and services that met professional standards of quality for a resident who was on blood thinner medication and sustained a fall in the bathroom. The resident, who was on Xarelto, a medication that increases the risk of bleeding, fell and hit their head, but the facility did not notify the physician in a timely manner. Despite the resident's increased blood pressure and complaints of head pain, the physician was not informed until approximately 10 hours after the fall, leading to a delay in emergency medical care. The facility's policy required timely notification of the physician for significant changes in a resident's condition, including accidents with potential for physician intervention. However, the staff failed to follow this policy. The resident's neurological assessments showed abnormal blood pressure levels, but there was no documented evidence that the physician was notified of these changes or the resident's anticoagulant medication use until much later. The resident eventually developed symptoms such as headache, nausea, and vomiting, prompting a transfer to the hospital where a subdural hematoma was diagnosed. Interviews with staff revealed a lack of awareness and communication regarding the resident's condition and medication. The nurse practitioner and registered nurses involved did not ensure timely reassessment or notification of the physician, contributing to the delay in care. The facility's failure to adhere to its own policies and procedures resulted in the resident not receiving necessary medical attention in a timely manner, ultimately leading to the resident's death in the hospital.
Plan Of Correction
Facility will immediately and accurately communicate with the physician/provider any pertinent change in condition of a resident. Notification of Changes in Resident's Status Policy has been reviewed and revised to include that the phone should be utilized or in person for all communication regarding significant change in status with physician/provider. Documentation to include physician/provider response. Education has been provided to all RNs and LPNs regarding the revised facility policy of Notifying Changes in Resident's Status. This education included assessing residents after change in condition, appropriate and complete notification of the physician/provider and method of notification. 85% of all RNs and LPNs have completed education by the end of the day 12/4/24. 100% of RNs and LPNs completed education by the end of the day 12/6/24. Every fall incident will be audited by interdisciplinary team to assure that appropriate and complete physician/provider notification has occurred. The audit will be reported on at Quality Assurance and Performance Improvement (QAPI) meeting by DON/Designee for a minimum of four quarters.
Removal Plan
- Facility will immediately and accurately communicate with the physician/provider any pertinent change in condition of a resident.
- Notification of Changes in Resident's Status Policy has been reviewed and revised to include that the phone should be utilized or in person for all communication regarding significant change in status with physician/provider. Documentation to include physician/provider response.
- Education has been implemented of all RNs (Register Nurse) and LPNs (Licensed Practical Nurse) regarding the revised facility policy of Notifying Changes in Resident's Status. This education includes assessing residents after change in condition, appropriate and complete notification of the physician/provider and method of notification. 85% of all RNs and LPNs will have completed education. 100% of RNs and LPNs will have completed education. If staff are not available, they will be educated prior to the start of their next shift in facility.
- Every fall incident will be audited by interdisciplinary team to assure that appropriate and complete physician/provider notification has occurred. The audit will be reported on at Quality Assurance and Performance Improvement (QAPI) for four quarters.