Failure to Assess and Respond to Bleeding in Anticoagulated Resident
Penalty
Summary
A resident with diagnoses including vascular dementia, cerebral infarction, and long-term use of anticoagulants was identified as being at risk for bleeding, with care plan interventions requiring staff to report any bruising or bleeding. During an observation, the resident was found to have a cut on the face with a small amount of blood, which appeared to be caused by a disposable razor during shaving. The nurse aide responsible for the shaving reported the incident to the nurse and cleaned the area, but the nurse did not assess the resident or document the incident, citing being too busy. The nurse also did not review the resident's record to determine anticoagulant use, despite being informed of the bleeding. Facility policy required observation for signs of bleeding in residents on anticoagulants and prompt notification of the practitioner for such findings. Additionally, the policy on physician notification for change of condition required assessment and intervention for significant clinical symptoms. The nurse involved did not follow these policies, as she neither assessed the resident nor notified the practitioner, and was unaware of the resident's anticoagulant therapy. The incident was further confirmed through staff interviews and review of facility policies.