Failure to Provide Timely Care and Physician Notification After Fall and Critical Lab Results
Penalty
Summary
The facility failed to provide appropriate care and treatment for a resident with a history of anemia, renal failure, and osteoarthritis, who was also at risk for bleeding due to anticoagulant (Warfarin) use. After the resident experienced a fall, staff observed bruising and pain, but there was no evidence that the physician was notified of these symptoms as required by the care plan and facility policy. The resident continued to exhibit bruising and pain over several days, and documentation failed to show timely physician notification or intervention regarding these ongoing symptoms of bleeding. Laboratory monitoring of the resident's INR, which is critical for patients on Warfarin, revealed dangerously high values on multiple occasions. Despite these critical lab results, the clinical record did not include evidence of timely notification to the physician or documentation of interventions in response to the abnormal findings. The resident's Warfarin was not discontinued until after a critical INR was reported, and there was a lack of documentation regarding the physician's response to the critical lab values and the resident's ongoing symptoms. Ultimately, the resident developed a significant bruise and pain in the left knee, which was later found to be fractured. The resident was transferred to the hospital, where laboratory results showed a critically low hemoglobin level and a supratherapeutic INR, necessitating a blood transfusion. The facility's failure to follow its own policies for monitoring, notification, and intervention after a fall and in response to abnormal lab results led to harm for the resident.