Failure to Assess and Intervene for Acute Bleeding in Anticoagulated Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a licensed nurse completed a timely assessment and intervention in response to an acute change in condition for a resident at high risk for bleeding due to anticoagulant therapy. The resident, who had a history of acute respiratory failure, morbid obesity, muscle weakness, and atrial fibrillation, was prescribed Rivaroxaban (Xarelto), increasing her risk for bleeding. On the day of the incident, the resident experienced a prolonged nosebleed shortly after receiving her anticoagulant medication. Staff provided only basic first aid measures, such as ice and washcloths, and there was no evidence of a licensed nurse performing a change-in-condition assessment or documenting vital signs during the episode. The facility's records lacked contemporaneous nursing documentation or assessment corresponding to the family-reported episode of active nasal bleeding. There was no documentation of a change-in-condition assessment, vital signs, or licensed-nurse follow-up related to the bleeding event. Additionally, the facility failed to reassess and document the resident's oxygenation status following the onset of the nosebleed, despite the resident's history of respiratory failure and current oxygen therapy. No new physician orders were entered, and there was no evidence of provider notification or new treatment orders related to the acute event. Interviews with staff revealed that the facility was short-staffed on the evening of the incident, and nurses were pulled from other wings to provide coverage. The administrator and nursing staff were unable to provide documentation of any nursing assessment, physician notification, or change-of-condition report related to the incident. The resident's family ultimately contacted emergency medical services to transfer the resident to the hospital for evaluation, as they were dissatisfied with the care provided during the episode.