F0684

J

Failure to Recognize Severity of Injury and Bleeding Risk in Anticoagulated Resident

Charlotte, North Carolina Survey Completed on 03-02-2026

Penalty

Fine: $26,685

Summary

The deficiency involves the facility’s failure to recognize the severity of an injury and the increased risk of bleeding in a resident receiving daily anticoagulant therapy, and to initiate timely emergency medical intervention. The resident had multiple diagnoses including diabetes mellitus, a prior tibia fracture, hypertension, osteoporosis, history of DVT, and was on Eliquis 5 mg twice daily for DVT prevention. Her care plan identified anticoagulant use as a risk factor, with interventions to observe for abnormal bleeding or bruising. On the day of the incident, a nurse aide was providing a bed bath and then assisted the resident into a wheelchair, placing her feet on pillows on the leg rests. While pulling the wheelchair backward alongside the bed, the resident’s left lower leg struck the damaged corner of the bed footboard, where laminate was missing and pressboard was exposed. The resident immediately cried out in pain, reporting pain at 10/10, and her lower left leg began bleeding.

The nurse aide attempted to control the bleeding by first using paper towels, which became saturated, and then a regular bath towel, while calling for a nurse. Nurse #1 entered, observed a one‑inch laceration on the resident’s left lower leg with increased bleeding, applied pressure for about five minutes, and then applied a pressure dressing. Nurse #1 documented the injury as a skin tear and noted that the resident’s anticoagulant was held, but did not initiate EMS or transfer the resident to a higher level of care, stating she did not think the resident needed to go to the hospital. Vital signs were documented as within or near normal limits, and no pain score was recorded in the SBAR note. The DON, who was in the facility at the time, did not go to the room or assess the wound and understood from Nurse #1 that the bleeding was controlled and that the resident did not need to be sent out immediately. The Medical Director later stated he was not informed that the resident’s leg had been struck on the footboard and that he would have sent her to the hospital due to her increased bleeding risk.

After staff left the room, the resident called her Responsible Party, who came to the facility, observed red blood on the white dressing, and, after learning the facility was not sending her out, called 911. EMS records show they were told by the nurse that the resident had a 1–2 inch laceration to the left lower leg, that bleeding had been controlled with gauze and tape, and that pain medication had been administered. EMS noted the resident was in emotional distress with a pain level of 10/10, elevated blood pressure and heart rate, and bruising and swelling of the left lower leg. At the hospital ED, the resident was found to have a 2 cm skin tear with drainage and a large associated hematoma measuring approximately 4 x 7 inches, with difficulty controlling bleeding at the facility cited as a reason for referral. During hospitalization, imaging and assessment identified a large superficial soft tissue hematoma measuring 16.2 cm, with a documented decline in hemoglobin from 11.1 to 7.3 over two days, consistent with acute blood loss anemia requiring transfusion, and subsequent necrosis over the hematoma that required surgical evacuation, debridement, and wound VAC placement. The facility’s failure to adequately assess the injury, consider the impact of anticoagulant therapy, and promptly initiate emergency medical intervention for active bleeding in this anticoagulated resident constituted the cited deficient practice.

Following discharge back to the facility, the resident required ongoing wound care and pain management. Wound care NP notes documented a large wound area on the left lower leg with necrotic tissue requiring daily dressing changes with Santyl and Dakin’s solution initially, later transitioning to xeroform and abdominal pads, with the wound described as improving but with a large surface area and low probability of full skin healing. The resident continued to report pain, particularly with dressing changes, and received frequent doses of oxycodone and acetaminophen for pain levels ranging from 0 to 10 on the pain scale. The Medical Director and Wound Care NP confirmed that the resident had sustained a significant hematoma requiring surgical intervention and that the wound remained a large open area. The surveyors determined that the facility’s failure to recognize the severity of the injury and the resident’s increased bleeding risk due to anticoagulant use, and to initiate timely emergency medical intervention, resulted in serious complications related to acute blood loss and extensive wound care needs for this resident.

The survey findings also noted that Nurse #1 was an agency nurse working her first day in the facility and did not follow facility policy on anticoagulants or significant change in condition, including appropriate monitoring and physician notification for residents on anticoagulation who exhibit excessive bruising or bleeding. The DON and Administrator acknowledged that they were informed of the incident after it occurred and that the primary focus at the time was obtaining an order to hold the evening dose of the anticoagulant, rather than assessing the full extent of the injury or the need for immediate transfer. The Medical Director later stated that a “red flag” such as increased bleeding and pain in an anticoagulated resident would warrant consideration of hospital transfer. The survey concluded that Immediate Jeopardy began when Nurse #1 failed to recognize the severity of the injury and the resident’s increased risk of bleeding due to anticoagulant use, and that this deficient practice affected one of three residents reviewed for quality of care.