Failure to Monitor and Intervene After Fall in Resident on Anticoagulant
Penalty
Summary
A deficiency occurred when the facility failed to ensure proper monitoring and intervention for a resident on long-term anticoagulant therapy following an unwitnessed fall. The resident, who had diagnoses including rheumatoid arthritis, atrial fibrillation, hypertension, and a history of transient ischemic attack, experienced a fall from a recliner, hitting their head and developing significant bruising. Despite the facility's policy requiring neurologic assessments and immediate physician notification for head injuries, there was no documentation that the physician was notified of the resident's change in condition after the fall. Subsequent nursing notes indicated the resident had increased bruising, low blood pressure, decreased oxygen saturation, and required more assistance, but these changes were not communicated to the physician. The LPN who reported the fall to the physician's nurse failed to mention that the resident was on a blood thinner, leading to a lack of appropriate medical response. The resident's condition further deteriorated, with pinpoint pupils and a mental status change observed two days after the fall, at which point the physician was finally notified and the resident was sent to the hospital. Interviews with staff confirmed that the resident should have been sent to the hospital immediately after the fall due to their anticoagulant use and head injury. The LPN acknowledged overlooking the resident's anticoagulant therapy and not reporting abnormal blood pressure readings or the development of two black eyes to the physician. The failure to follow established protocols for monitoring and physician notification after a significant change in condition resulted in a delay in appropriate medical intervention.
Removal Plan
- Staff will identify residents on anticoagulants at shift change by notifying oncoming staff at shift change of all residents on anticoagulants.
- Administration will post a roster in the medication room of all residents on anticoagulants.
- Administration will post a roster in the medication room of all anticoagulant medications.
- Will adjust EHR resident dashboard to indicate the use of anticoagulant medication.
- Immediate In-Service Education of medication management with a focus on high-risk drugs like anticoagulants for nursing staff and CMAs.
- Competency assessments will be completed by nursing administration including demonstrations of skills, med-administration, side effects and monitoring requirements.
- All residents were reassessed for changes in condition and care plans were updated for discrepancies.
- Nursing staff were educated on monitoring residents through routine assessments, ongoing observation, and documentation. This includes checking vital signs, evaluating physical and mental status, and noting any changes in behavior, appearance, or function.
- Staff are now trained to recognize both subtle and obvious changes in residents' health, such as increased confusion, changes in mobility, altered appetite, new or worsening pain, or unusual sleep patterns.
- Nursing Staff were educated on promptly notifying the physician whenever there is a significant change in the condition of a nursing home resident on anti-coagulants. This includes any acute medical events, substantial changes in physical or mental status, or any situation that may require a change in treatment or intervention. Notification should occur as soon as reasonably possible after the change has been identified by nursing staff, in accordance with regulatory guidelines and the facility's policies.
- Nursing home nursing staff will receive dedicated training focused on the indications for commonly used medications, with special emphasis on blood thinners. The training will cover: Overview of blood thinners: indications, expected outcomes, and common side effects. Recognizing signs and symptoms of adverse reactions or complications (e.g., bleeding, bruising, changes in mental status, or unexplained pain). Monitoring protocols for residents on blood thinners, including vital signs, laboratory values, and physical assessments. Documentation requirements and communication procedures for reporting changes in resident conditions. Emergency response procedures for suspected medication-related complications.
- The training will be delivered by the facility's Director of Nursing, in collaboration with the facility pharmacist consultant and CHV nurse consultant.