Failure to Timely Notify Physician After Resident Fall
Penalty
Summary
The Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility, resulting in a deficiency related to the care of Resident R17. The resident, who was on the anticoagulant medication Xarelto, fell in the bathroom and hit their head. Despite the elevated risk of bleeding due to the medication, the staff did not notify the physician in a timely manner. The incident report documented the fall at 2:05 a.m., but the physician was not notified until 3:40 p.m., and there was no evidence of a physician response. Following the fall, Resident R17 exhibited elevated blood pressure and complained of pain, yet the staff did not reassess the resident's condition in a timely manner. The resident's neurological assessments showed consistently high blood pressure, but there was no documentation of physician notification regarding these findings. The resident was eventually transferred to the hospital after developing symptoms such as headache, nausea, and vomiting, where a CT scan revealed a subdural hematoma. The resident passed away at the hospital due to the injury. Interviews with facility staff, including the night shift supervisor and the physician, revealed a lack of appropriate communication and follow-up procedures. The staff failed to notify the physician of the resident's anticoagulant use and high blood pressure, which could have influenced the medical response. The NHA and DON confirmed the deficiencies in staff actions and documentation, acknowledging the failure to meet federal and state guidelines, which contributed to an Immediate Jeopardy situation.
Plan Of Correction
The Nursing Home Administrator and Director of Nursing will fulfill essential duties and responsibilities of their position to ensure that the Federal and State guidelines and regulation are followed. Nursing Home Administrator and Director of Nursing reviewed and revised the Notification of Changes in Resident's Status Policy. The revision includes 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. Nursing Home Administrator and Director of Nursing will continue to attend continuing education (CEU) approved by their state boards on a biennial basis. NHA will continue to complete 48 hours of continuing education every two years that are approved by the Board of Examiners of Nursing Home Administrators or National Association of Long-Term Care Administrator Boards (NAB). DON will continue to complete 30 hours of continuing education every two years that are approved by the State Board of Nursing. NHA/Designee and DON/Designee will conduct a root cause analysis on all reportable incidents submitted to Department of Health. Reportable incidents and their root cause analysis will be reported on at Quality Assurance and Performance Improvement (QAPI) meeting for a minimum of four quarters by NHA/Designee.