Failure to Notify Physician of Change in Condition After Fall with Head Trauma
Penalty
Summary
The facility failed to ensure timely and appropriate physician notification following a significant change in condition for a resident who experienced a fall with head trauma. The resident, who had a medical history including atrial fibrillation and was prescribed Xarelto (a blood thinner), sustained a head injury after an unwitnessed fall. Facility policy required immediate physician notification and neurological assessment for any head trauma, especially for residents on anticoagulants. However, documentation and interviews revealed that the physician was not informed that the resident was on a blood thinner at the time of the initial notification, and critical details such as abnormal blood pressure readings and the development of new injuries (including two black eyes and additional bruising) were not promptly communicated. Nursing notes indicated that the resident developed worsening symptoms over the following days, including increased bruising, new injuries, and abnormal vital signs. Despite these changes, there was no evidence that the physician was updated about the resident's deteriorating condition or the significance of the blood thinner therapy. The resident continued to receive Xarelto, and neuro checks were performed, but the escalation of symptoms and abnormal findings were not reported as required by facility policy. It was only after a significant decline in neurological status, including confusion and pinpoint pupils, that the physician was notified and the resident was transferred to the hospital, where a diagnosis of acute subdural hematoma was made. Interviews with facility staff, including the LPN and ADON, confirmed that the physician should have been notified immediately after the fall due to the resident's anticoagulant use and that subsequent changes in condition warranted further communication, which did not occur.