Failure to Ensure Nursing Staff Competency in Change of Condition for Resident on Anticoagulant
Penalty
Summary
Nursing staff failed to demonstrate appropriate competency in assessing, monitoring, and intervening for a resident who was on a routine blood thinner and sustained a fall with a head injury. The resident, who had a history of atrial fibrillation and heart failure and was prescribed Xarelto, experienced a fall resulting in a head injury and subsequent acute subdural hemorrhage. Despite facility policy requiring neurological assessments and immediate physician notification for head trauma, staff did not communicate the resident’s anticoagulant use to the physician and did not send the resident to the hospital immediately after the fall. Documentation showed that after the fall, the resident developed a large hematoma, bruising, and later two black eyes and additional bruising, with abnormal blood pressure readings noted. Staff continued to monitor the resident in the facility, performing neuro checks and documenting changes, but failed to recognize or report significant changes in condition, including abnormal vital signs and new injuries, to the physician in a timely manner. The resident’s condition deteriorated over the following days, culminating in confusion, pinpoint pupils, and slow responsiveness, at which point the resident was finally transferred to the hospital and diagnosed with an acute subdural hematoma. Interviews with staff revealed a lack of awareness regarding the importance of reporting anticoagulant use and abnormal vital signs after a fall. The LPN involved admitted to overlooking the resident’s blood thinner status and not communicating critical information to the physician. The DON and ADON acknowledged that the facility’s process for physician notification after a fall was not consistently followed, and that annual competency check-offs for nursing staff had not been completed.
Removal Plan
- All nursing staff complete Skills Competency proficiency of change of condition with a focus on high-risk drugs like anticoagulants.
- DON and ADON are in-serviced on training and completing nursing skills competency education for nursing staff.
- All residents are reassessed for changes in condition and care plans are updated for discrepancies.
- DON and ADON are educated on auditing nursing staff annual skills competency education.
- DON and ADON are educated on auditing nursing staff new hire skills competency education.
- Nursing staff complete testing regarding changes in condition, medication drug class identification, and recognizing vital signs.
- Nursing staff are educated on what constitutes a significant change in condition that requires reporting, including sudden onset of symptoms, significant changes in vital signs, new or worsening pain, changes in mobility, altered level of consciousness, signs of infection, unexplained weight loss or gain, and changes in skin integrity.