Failure to Prevent and Address Recurrent Hand Injuries in Resident on Anticoagulant
Penalty
Summary
A deficiency was identified when a resident who ambulated independently in a wheelchair was observed with bruising on both hands, specifically on the knuckles and backs of the hands. The resident reported that the bruising occurred from bumping their hands while self-propelling the wheelchair and noted that they bruise easily due to being prescribed an anticoagulant (Xarelto). The resident's care plan included monitoring for signs and symptoms of bleeding due to anticoagulant use, but there was no documentation of the bruising or any assessment following the incident. Additionally, the facility's policy required that all accidents or incidents be investigated and reported, and that trends be reviewed for safety hazards, but this was not followed in this case. Interviews with staff revealed that no interventions had been implemented to prevent further injury to the resident's hands, and the bruising was neither documented in the treatment administration record nor reported through an incident report. The ADON acknowledged that the only intervention had been resident education conducted at the time of admission, and the DON confirmed that the resident was not assessed after reporting the injuries. There were no interventions in place to address the recurring bruising related to the resident's use of a wheelchair or walker.