F0580

D

Delayed Physician Notification After Resident Fall With Head Injury on Dual Antiplatelet Therapy

Palestine, Texas Survey Completed on 01-07-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to promptly notify a resident’s physician after an accident that resulted in a head injury. A male resident with end stage renal disease, dependence on dialysis, atherosclerotic heart disease, and intact cognition (BIMS 15) was on dual antiplatelet therapy with aspirin and clopidogrel for a prior myocardial infarction. His care plan included monitoring and reporting changes or increases in bruising. In the early morning, the resident fell while attempting to get up from his wheelchair to get coffee, tripped over the footrest, and struck the right side of his face and head on the floor. He reported head pain to the nurse, who told him it would improve when the swelling went down. The fall was unwitnessed and documented at 3:00 a.m. by an LVN who found the resident on his right side, assisted him back to his wheelchair, noted a bump/hematoma on his forehead, administered Tylenol, applied an ice pack, and initiated neurological checks.

The fall report showed that the resident was alert and oriented with a reported pain level of 6/10 and normal vital signs, and that the physician was not notified until 4:21 a.m., an 81‑minute delay. The facility’s neurological assessment sheet documented that at 3:20 a.m. the resident was not fully oriented, with subsequent assessments between 3:00 a.m. and 5:35 a.m. showing no confusion/disorientation and stable vital signs. The LVN stated he texted the physician but was unsure of the time, and reported that the resident was confused and unstable, and that he notified the family at 3:00 a.m. but delayed notifying the physician. A dialysis communication form completed by the same LVN shortly after indicated there were no new problems or concerns. The resident later reported that he was not offered to go to the ER and that he went to dialysis first, after which the doctor there sent him to the ER.

Interviews with staff and the physician highlighted inconsistent expectations and practices regarding physician notification. An RN stated that if a resident on antiplatelet medication fell and had a head injury, he would call the physician immediately or as soon as possible due to the risk of brain bleeding, and that any neurological changes should prompt further contact. The ADON stated she expected immediate physician notification after a fall with head injury, especially for residents on antiplatelet therapy, citing increased risk of brain bleeding. The DON, however, stated that as long as neurological checks were normal there was no reason to contact the physician sooner and felt the 81‑minute delay and use of text notification were acceptable. The attending physician reported that standard teaching for a patient on clopidogrel with a head injury is usually to go to the ER, and that he was unaware of the 81‑minute delay. The facility’s policy on change in condition required prompt notification of the attending physician when there has been an accident or incident involving the resident.