Failure to Notify Physician and Discontinue Blood Thinners After Resident Head Injury
Penalty
Summary
The facility failed to notify a resident's physician of a significant change in condition following a head injury, despite the resident being on blood-thinning medications (Aspirin and Clopidogrel) for stroke prevention. After sustaining a head injury that resulted in an abrasion, laceration, a bump, and substantial bleeding, the resident's physician was not promptly informed. The resident continued to receive blood thinners for several days after the injury, as no order was obtained to discontinue these medications, and the care plan's instructions to monitor and report adverse reactions were not followed. Staff interviews and record reviews revealed that although a registered nurse attempted to contact the physician by voicemail and text message, there was no confirmation of a response or follow-up, and no further action was taken to ensure the physician was notified. Other nursing staff continued to administer the blood thinners, assuming the physician had been informed, and did not independently verify or escalate the situation. The resident subsequently exhibited noticeable changes in behavior, including decreased appetite, drowsiness, and reduced communication, which were not typical for him and were not reported to the physician as required by the care plan. The lack of timely physician notification and continued administration of blood thinners resulted in a delay in evaluation and treatment. The resident was eventually found lethargic and unarousable by a family member and was transferred to a hospital, where he was diagnosed with a subarachnoid hemorrhage and required a platelet transfusion. Facility policy required prompt physician notification in the event of accidents or significant changes in condition, but this was not adhered to in this case.