Failure to Provide Post-Fall Monitoring and Timely Assessment for Anticoagulated Resident
Penalty
Summary
A resident with a history of falls, cervical fracture, and on anticoagulation therapy was admitted to the facility and identified as a high fall risk. The care plan included interventions such as keeping the call bell within reach, ensuring non-skid footwear, and encouraging the resident to request assistance for mobility. Despite these interventions, the resident experienced multiple falls during their stay, including unwitnessed incidents and falls resulting in injury. After each fall, documentation shows that only minor or previously implemented interventions were added, and there was no evidence of significant revision to the care plan to address the ongoing pattern of falls. Following an unwitnessed fall with possible head impact, the resident, who was on anticoagulation therapy, was not transferred for immediate medical evaluation or diagnostic imaging as recommended by professional standards and facility policy. Although a physician ordered 15-minute safety checks and neurological assessments after the fall, documentation revealed that these were not consistently performed or communicated to all staff. The neurological assessment flow sheet showed gaps in monitoring, and the facility could not provide evidence that the required 15-minute safety checks were completed. The DON confirmed that staff were unaware of the order for increased monitoring due to a lack of communication. Subsequently, the resident was found unresponsive approximately 13 hours after the fall, with no documented neurological assessments in the five hours prior. Emergency services were called, and the resident was transferred to the hospital, where diagnostic imaging revealed a large subdural hematoma and multiple areas of brain bleeding. The resident was pronounced deceased following further evaluation. The facility failed to ensure that treatment and care were provided in accordance with professional standards of practice, including prompt evaluation and monitoring after a fall in an anticoagulated resident, as well as proper implementation and documentation of physician-ordered interventions.
Plan Of Correction
1. Unable to retro correct deficient practice for Resident CR1. 2. Facility will review residents on anticoagulation therapy who have had a fall in the past 48 hours. Physician will be contacted with post fall assessment findings including neurological evaluation to determine whether residents need to be transferred to the hospital for evaluation. 3. Nursing Educator/ designee will provide education to licensed staff facility on post fall protocols including MD notification to include anticoagulant use and neurological evaluation. 4. Director of Nursing / designee to complete audits on 5 falls weekly to ensure that interventions are initiated to address risk for falls and interventions to prevent reoccurrence. Audits will also include neurological evaluations on unwitnessed falls and q 15-minute checks if applicable, and MD notification if the resident is on anticoagulation therapy. Audits will continue x 8 weeks and findings will be reviewed by the facility QAPI committee. F 0684