Delayed Emergency Response for Anticoagulated Resident After Fall
Penalty
Summary
A facility failed to provide treatment and care in accordance with professional standards of practice for a resident who was prescribed an anticoagulant. The resident, an elderly female with a history of metabolic encephalopathy, cerebral infarction, hypertensive heart disease, chronic kidney disease, and heart failure, experienced an unwitnessed fall in her room, striking her head. Upon assessment, she exhibited bruising and swelling to her left eye but reported no pain. The nurse on duty initiated neuro and skin assessments, found her vital signs to be normal, and notified the responsible party, DON, and nurse practitioner (NP), who ordered immediate transfer to the hospital for further evaluation. Despite the NP's order for immediate transfer, there was a significant delay in dispatching and transporting the resident to the hospital. The transport was not dispatched until over two hours after the fall, and the resident was not transported until nearly four hours after the incident. During this time, neuro checks and vital signs were monitored and remained within normal limits. The nurse chose to use regular transport rather than 911, citing the resident's stable condition, and did not recall if the NP specified the mode of transport. The resident's family member arrived at the facility during this period and accompanied her to the hospital. Upon arrival at the hospital, imaging revealed no acute intracranial hemorrhage, but the resident later passed away. The death certificate listed intracranial hemorrhage and atrial fibrillation as causes of death. Interviews with facility staff revealed uncertainty regarding the appropriate mode of transport for residents on anticoagulants with head injuries and inconsistent understanding of protocols for such incidents. The facility's failure to ensure timely and appropriate emergency response for a resident on anticoagulant therapy who sustained a head injury constituted a deficiency in providing care according to professional standards.