Nursing Staff Unaware of Anticoagulant Use During Fall Incident
Penalty
Summary
Nursing staff failed to demonstrate competency in being aware of a resident's anticoagulant medication use, which was necessary for proper monitoring and care. A resident with heart disease was prescribed Xarelto, an anticoagulant, and the care plan required staff to monitor for complications and review medications for adverse interactions. Despite these requirements, a registered nurse involved in a fall incident with the resident was unaware that the resident was taking an anticoagulant. The nurse had not read the resident's care plan and only became aware of the medication after the fall occurred. Following the fall, the resident developed significant bruising and a hematoma on the face, which worsened over time. The nurse, as well as other facility staff interviewed, confirmed that nursing staff are expected to be familiar with residents' medications and care plans. The lack of awareness regarding the resident's anticoagulant use was confirmed through interviews with the nurse, nurse practitioner, registered nurse consultant, and medical director, all of whom stated that the nurse should have known about the medication prior to the incident.