Failure to Notify Provider of Fall With Head/Mouth Injury for Anticoagulated Resident
Penalty
Summary
The deficiency involves the facility’s failure to notify the provider immediately after a resident experienced a fall with injury. The resident’s care plan dated 11/26/2025 documented that the resident was at risk for falls and required assistance with transfers and ambulation, with interventions including maintaining the bed at an appropriate height and ensuring the call light was within reach. According to an SBAR dated 12/22/2025 at 8:05 AM, an LPN documented that approximately 12 hours earlier the resident’s knees buckled in the shower room, causing the resident’s face to come into contact with a handrail and resulting in broken dentures, bleeding, and mouth pain rated 8/10. The resident was prescribed Apixaban (Eliquis), an anticoagulant, 5 mg BID. The LPN who worked the following day stated she received report that the resident had fallen in the shower, then assessed the resident and noted dried blood on the lip and complaints of mouth pain. She stated it was her understanding that the nurse on the prior shift had not notified the provider when the resident fell and hit her head. The nurse practitioner’s progress note dated 12/23/2025 documented that the fall was not reported to the provider until the oncoming nurse received report the following morning, and that the incident was not documented in the electronic medical record in a timely manner, with no nursing notes available for review. The NP noted that the resident was on Eliquis and that any reported or suspected head strike while on anticoagulation warrants immediate transfer to the emergency department and at minimum a STAT head CT. The NP stated she was not notified of the fall and head/mouth injury when it occurred and that she would have expected staff to notify her because of the resident’s anticoagulant use and need for physician assessment. The facility’s Reporting of Injuries Policy, revised 12/2025, states that serious incidents such as head injuries are to be reported to the physician at the time of occurrence, using SBAR to convey assessment findings and pertinent medication information, and that all charting should include notification of the doctor. These policy requirements were not followed for this resident’s fall with head/mouth injury.
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