Failure to Recognize and Respond to Post-Fall Injuries in Anticoagulated Resident
Penalty
Summary
The deficiency involves the facility’s failure to recognize, assess, and appropriately respond to a resident’s injuries after a fall, resulting in neglect as defined by the facility’s Abuse and Neglect policy. The resident, who was receiving two daily anticoagulants (Clopidogrel at bedtime and Aspirin in the morning) with orders to monitor for side effects such as bruising and sudden changes in mental status, fell during incontinence care on February 15, 2026. At 2:50 PM, an LPN documented abrasions, bruising, and redness to the right side and left upper back, a mark on the left forehead, and discoloration to the right knee, right arm, and right elbow, indicating a possible head injury. The resident’s daughter reported that when she arrived after being notified of the fall, she observed red marks on the resident’s head and back, noted that the resident was in a lot of pain, and acting differently by talking louder than usual despite usually being soft spoken and quiet. She stated that the LPN told her the physician had been notified, an X-ray ordered, and Tylenol given for pain. The facility’s nurse practitioner later reported that the LPN had informed him only that the resident had fallen from the bed and was reporting pain in both legs, and that he gave a verbal order for an X-ray without being made aware of the visible injuries. He stated that he was not informed of the full extent of the injuries, including the documented head and multiple body injuries, and that his decision-making was based on incomplete information. The first notation of a possible head injury was at 2:50 PM, and subsequent documentation at 7:47 PM by another LPN described the resident as nauseated, vomiting, experiencing shortness of breath, and becoming unresponsive, leading to transfer to the hospital at approximately 9:15 PM. The resident’s daughter later notified the facility at 1:00 AM on February 16, 2026, that the resident had passed away. The failure to fully assess and communicate the extent of the injuries and potential anticoagulant-related concerns following the fall constituted neglect under the facility’s policy, as necessary services to avoid physical harm and pain were not provided.
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