Failure to Provide Post-Fall Care and Monitoring for Resident on Anticoagulants
Penalty
Summary
A deficiency occurred when a resident with a history of stroke, hypertension, and on blood thinners (aspirin and clopidogrel) experienced a fall in the facility. The resident was found on the bathroom floor after attempting to transfer herself from her wheelchair to the toilet. The nurse assessed the resident for injuries and reported none were found, but the resident stated she hit the back of her head. The nurse notified the physician's office, which instructed to follow protocol, and neuro checks were initiated. However, there was confusion and lack of clarity regarding the facility's protocol for residents on anticoagulants who sustain a head injury, with some staff believing the resident should have been sent to the hospital, while others stated monitoring was sufficient. Documentation and communication failures were evident throughout the incident. The time of the fall was not clearly documented, and there were missing or incomplete entries regarding interventions and physician feedback. Neuro checks were not completed as ordered, with the last documented check at 2:45 a.m. and the next scheduled check at 6:45 a.m. missing. The resident was last seen at approximately 4:30 a.m. and was found unresponsive at around 7:20 a.m. There was also a lack of proper handoff between shifts, with CNAs and nurses not consistently giving or receiving reports, and some staff unaware of the fall or the resident's condition changes. Interviews with staff revealed inconsistencies in understanding and following protocols for post-fall care, especially for residents on blood thinners. Some staff were unaware of the resident's anticoagulant status, and there was no clear written policy on whether such residents should be sent to the hospital after a head injury. The facility's documentation, monitoring, and communication lapses contributed to the resident not receiving care and services in accordance with professional standards and the comprehensive care plan, ultimately resulting in the resident's death.