Failure to Immediately Notify Resident Representative After Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify a resident’s representative of a significant change in condition following an accident that resulted in injury. The resident had atrial fibrillation and was receiving Apixaban (Eliquis) 5 mg orally every 12 hours as an anticoagulant, with this therapy reflected in both physician orders and the care plan. In the early morning, nursing documentation recorded that while staff were assisting the resident from a wheelchair to the toilet, the resident bent forward, hit her head on the wall, and sustained a 3 cm by 3 cm hematoma on the forehead and a skin tear to the right upper shin. Neuro checks were initiated, but the resident was uncooperative with certain components of the assessment, including pupil checks and hand grasps. Later that morning, a medical provider documented that the resident had fallen, hit her head, was on Eliquis, and had a hematoma to the right upper forehead, and recommended transfer to the ER for further evaluation and treatment. Nursing documentation shortly thereafter noted the hematoma, the resident’s use of Eliquis, receipt of an order to send the resident to the ER, and that staff spoke with the resident’s family, who agreed to the transfer. Subsequent documentation indicated that the resident’s representative was upset because they were not called when the resident initially hit her head and believed the resident should have been sent to the hospital as soon as possible. There was no evidence that the responsible party was notified of the incident and resulting injury at the time it occurred, and notification did not occur until approximately seven hours later when the resident was being transferred to the hospital, constituting a failure to immediately notify the resident’s representative of an accident involving injury that had the potential to require physician intervention.
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