Failure to Assess and Notify Provider After Fall in Anticoagulated Resident
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, monitor, and notify the physician of a change in condition for a resident on anticoagulant therapy following a fall. The resident had moderately impaired cognition and multiple diagnoses including stroke, chronic heart failure, gait and mobility abnormalities, and a stage 2 pressure injury on admission. The care plan identified a self-care deficit and moderate fall risk with interventions for assisted ambulation, ADLs, and call light use, but did not include a focus on anticoagulation management with individualized goals and treatment management, despite active warfarin orders. On the evening of the fall, the resident self-reported an unwitnessed fall and was found in a recliner with a reopened coccyx wound and bleeding from the bottom. The post-fall assessment documented normal range of motion, no pain, orientation to person, and the resident’s denial of head strike, with predisposing factors including impaired memory, gait imbalance, and ambulating without assistance. Although documentation indicated multiple notifications, the physician was not actually notified at the recorded time, and neurological checks were not initiated, contrary to facility expectations for unwitnessed falls and residents on anticoagulants. A follow-up note in the early morning hours documented stable vital signs and no new physical findings, stated that the provider did not need to be notified, and lacked any neurological assessment. Later that night, frank blood in the toilet was observed by a nursing assistant, and a progress note recorded this change along with stable vital signs, but again lacked a neurological assessment and provider notification. A subsequent note indicated no blood after toileting and attributed prior bleeding to a skin tear from the fall. Later that morning, the resident was documented as lethargic, oriented x2, with breakthrough bleeding on the right gluteal/thigh region and head pain rated 7/10, and was transferred non-emergently to the ED. In the ED, the resident was noted to have fallen while on blood thinners, complained of head pain, and had an elevated INR of 5.3, with CT scans negative for acute changes and warfarin dosing later adjusted. The DON and nursing staff interviews confirmed that neuro checks were not initiated after the unwitnessed fall, the provider was not notified at the time of the fall or when frank blood was first noted, and that these actions were inconsistent with facility policies on change of condition and fall management, particularly for residents on anticoagulants.
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