Failure to Recognize Severity of Injury and Bleeding Risk in Anticoagulated Resident
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.
Removal Plan
- ADON audited the electronic health record order listing report to identify all residents receiving anticoagulant therapy and established this as an ongoing audit updated with each admission.
- DON audited all incident and accident reports for the past 30 days to ensure any incident resulting in injury received timely and appropriate treatment.
- Licensed nurses completed a facility-wide skin assessment for all residents receiving anticoagulant therapy to ensure no excessive bruising or bleeding and documented results in the electronic health record.
- Administrator and DON completed a root cause analysis identifying lack of recognition by an agency nurse of the need to transfer a resident to the ED and failure to follow the anticoagulant/significant change in condition policy.
- Held an ad hoc QAPI meeting to review the deficient practice and plan of correction.
- Administrator reviewed facility policy and clinical protocol for anticoagulation and change in condition and determined no changes were warranted.
- DON educated all licensed nurses, including agency nurses, on recognition and assessment of abnormal bruising and bleeding for residents on anticoagulants, use of e-interact tools, notifying MD/NP when an anticoagulated resident sustains an injury, and seeking a higher level of treatment for continued bleeding after 15 minutes of pressure or a pressure dressing.
- Incorporated the licensed-nurse education into orientation and onboarding for newly hired nursing staff, including agency nurses, with DON or designee to provide education and electronic training at onboarding.
- DON and ADON track and maintain education records to ensure staff receive the licensed-nurse education prior to start of their next shift.
- DON educated all nurse aides on recognizing changes in condition including excessive bleeding and on using the Stop and Watch Tool to immediately alert licensed nursing staff.
- Incorporated the nurse aide education on Stop and Watch and change in condition into orientation for newly hired staff, including agency staff, provided by DON or designee.
- Administrator is responsible for execution of the credible allegation and immediate jeopardy removal plan.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Follow Care Plan for Protective Sleeve: A resident with severe cognitive impairment, Alzheimer’s disease, dementia, and PVD had a care plan directing staff to keep protective sleeves on the left elbow at all times due to skin tear risk. During repeated dining room observations, the resident was not wearing the sleeve. A NA said she did not apply it because the resident would remove it and chew on it, and an RN said he was unaware the sleeve was not being worn.
Failure to follow wound care orders and dressing documentation requirements was cited for multiple residents. A resident had a skin tear dressed without a physician order, another resident had a knee dressing with no date or initials, and a third resident had a dated dressing and pain patch that did not reflect the ordered treatment schedule. The DON and wound care RN acknowledged that dressings and treatments should be completed as ordered and that dressings are expected to be dated and initialed.
Failure to Follow Ordered Treatments and Weight Monitoring: The facility did not ensure ordered care was carried out for several residents. One resident with Parkinson’s disease and anxiety sustained a skin tear to the hand during an agitated episode, but there was no physician order for the wound treatment that was provided. Two residents had ordered weekly weights that were not obtained as scheduled, and the records did not explain why. Another resident with HTN, depression, and DM had body blisters, but the wound company’s recommendation for skin prep was not entered as an order, and there was no documented evidence that the practitioner was contacted about the missed recommendation.
Failure to Follow Insulin Orders: Two residents with diabetes received insulin contrary to physician orders. One resident was given insulin aspart at times when blood glucose was below the ordered hold parameter, and a second resident received scheduled insulin without documented meal intake despite orders to hold if blood sugar was low or if less than 50% of the meal was eaten. The DON confirmed the medication administration did not follow the orders.
Failure to follow bowel management protocol: three residents had extended periods without a BM and no documented nursing interventions despite the facility’s protocol requiring specific measures after 2, 3, 4, and 5 days without a BM. The residents had significant diagnoses including schizophrenia, Parkinson’s disease, stroke, TBI, and Alzheimer’s disease, and the RNC confirmed the missing BM-related interventions in the chart.
A resident with dementia, severe cognitive impairment, limited ROM in both LEs, and dependence on staff for wheelchair locomotion was observed sitting in her wheelchair with her feet hovering above the footrests. CNAs confirmed her feet did not reach the footrests, and an administrative nurse stated the footrest needed to be adjusted to better fit and support her feet.
Failure to Follow Care Plan for Protective Sleeve
Penalty
Summary
The facility failed to ensure a sleeve protector was provided in accordance with the comprehensive care plan for a resident with severe cognitive impairment, Alzheimer’s disease, dementia, and peripheral vascular disease. The resident’s admission MDS identified the resident as needing partial/moderate assistance with upper body dressing and footwear and as being at risk for pressure ulcer/injury without existing pressure ulcers. The Pressure Ulcer/Injury CAA identified the resident as at risk for pressure ulcers and in need of a pressure relieving device for the bed and chair. The resident’s care plan, revised 7/28/26, identified a skin tear/potential for skin tear of the left anterior shin and left posterior calf related to falling and hitting self on the wheelchair, and directed staff to keep protective sleeves on the left elbow at all times. During multiple observations in the dining room, the resident was seated in a tilt-in-space wheelchair and was not wearing the protective sleeve to the left elbow. A NA stated she had been assigned to the resident all week and did not put the sleeve on because the resident would take it off and chew on it. An RN stated he was unaware the resident was not wearing the sleeve but said the resident should wear it if it was care planned. The DON stated the sleeve protector should be assessed and removed from the care plan if inappropriate, but staff were expected to follow the care plan to ensure the resident received the needed care.
Failure to Follow Wound Care Orders and Dressing Documentation
Penalty
Summary
The facility failed to ensure physician orders and facility policy were followed for wound care for 3 of 10 residents reviewed for wounds. Resident #28 was observed with a gauze dressing to the right wrist dated 08/06/2026, and the nursing note documented that a CNA noticed a new skin tear to the right wrist that was bleeding, was assessed by the nurse, cleaned, and dressed. However, review of the physician orders showed no wound care order for the right wrist. The wound care RN stated the resident did not have any wounds to her knowledge and explained that when a resident gets a skin tear, the nurse should cleanse it, recover the skin, dress it, notify the physician and family, and enter new orders. The DON stated the resident did not have orders for wound care to the right wrist and that the LPN should have notified the provider and obtained orders. Resident #21 was observed with an island dressing on the right knee that had no date or initials. The DON stated dressings are expected to be dated, and the wound care RN stated it is her practice to date and initial every dressing change, with weekend and PRN dressing changes done by the nurse on the cart. The TAR directed daily cleansing and application of a long island dressing to the right knee surgical site, and the facility policy for clean/dry dressings required tape/labels with date and initials. Resident #113 was observed with a dressing dated 8/6 and a white pain patch on the left arm dated 8/6/2026. The physician order required cleansing the left arm skin tear and applying xeroform, honey gel, and border gauze every day shift, and another order directed Aspercreme Lidocaine Patch 4% to the left shoulder in the morning and night and to the left hip with removal at bedtime. The wound care RN stated she was not familiar with the resident's skin tear dressing orders and that wound care should be done as ordered, while the DON stated dressings and treatments should be done as ordered and a check mark in the treatment record means completed.
Failure to Follow Ordered Treatments and Weight Monitoring
Penalty
Summary
The facility failed to provide appropriate treatment and care in accordance with orders and professional standards for four residents. Facility policy stated that weights were to be obtained routinely to monitor nutritional health, including weekly for the first four weeks after admission or readmission and more often if risk was identified or as ordered. For one resident with diagnoses including high blood pressure, Parkinson’s disease, and anxiety, a nursing note documented that the resident sustained a skin tear to the right hand during an episode of agitation and attempted physical aggression toward staff while being assisted out of bed. The wound nurse confirmed there was no physician order for treatment of the right hand skin tear, although steri-strips had been applied and the wound nurse stated steri-strips are the preferred treatment for skin tears. For two residents, physician orders required weekly weights, but the clinical record did not show that the ordered weights were obtained as directed. One resident had weights not obtained on two scheduled dates, and the record lacked additional documentation explaining why the weights could not be obtained. Another resident had one missed weekly weight, and the record also lacked additional documentation explaining why the weight was not obtained. The DON confirmed that the facility failed to make certain these residents were provided appropriate treatment and care. For another resident with diagnoses including hypertension, depression, and diabetes, the record showed the resident was admitted with marks and blisters on the body and no treatment was ordered. A contracted wound company later recommended skin prep to the blisters, but physician orders did not include skin prep. A wound nurse stated there was no order for skin prep and confirmed the facility did not follow the wound company’s recommendations. An RN stated the recommendations were not followed, but the facility had no documented evidence of speaking with the practitioner about treatment for the blisters or the reason the recommendations were not followed.
Failure to Follow Insulin Orders
Penalty
Summary
The facility failed to follow physician orders for two residents receiving insulin. One resident was cognitively intact, required maximum assistance with daily care needs, had diabetes, and was ordered to receive 6 units of insulin aspart at 8:00 a.m. with instructions to hold the medication if blood sugar was less than 110 mg/dL. Review of the MAR showed the resident received the insulin on multiple occasions when blood sugar readings were below that threshold, including readings of 92, 106, 105, 104, 94, and 75 mg/dL. The DON confirmed that the insulin had been administered on those dates and should have been held per the physician's order. A second resident was cognitively impaired, dependent on staff for daily care needs, and had insulin-dependent diabetes. The physician ordered 6 units/mL of insulin aspart twice daily with lunch and supper, with instructions to hold the dose if blood sugar was less than 150 mg/dL or if the resident ate less than 50 percent of the meal. The MAR showed no documented meal intake for several lunch and dinner meals on specified dates, yet the insulin was still administered. The DON confirmed that staff should have obtained the resident's meal intake before giving the insulin on those occasions.
Failure to Follow Bowel Management Protocol
Penalty
Summary
The facility failed to follow its Bowel Management - Clinical Protocol for residents who did not have a bowel movement within the required time frame. The protocol dated April 2026 directed staff to assess, monitor, and manage bowel and bladder function according to individualized needs and physician/provider orders, with specific interventions beginning on Day 2, Day 3, Day 4, and Day 5 without a BM. For Resident #31, the record documented no BM from 7/27/26 at 2146 to 7/31/26 at 2130, with no documented nursing interventions during that period. Resident #31 had diagnoses including schizophrenia and alcohol abuse. Resident #4’s record documented no BM from 7/9/26 to 7/12/26 with no documented nursing interventions related to the lack of BM during that time. Resident #4 had diagnoses including Parkinson’s Disease and major depressive disorder. Resident #56’s record documented no BM from 7/21/26 to 7/28/26 and again from 7/29/26 to 8/2/26, with no documented nursing interventions during those periods. Resident #56 had diagnoses including stroke, traumatic brain injury, and Alzheimer’s disease. On 8/5/26, the RNC stated that Residents #4, #31, and #56 had no documented BM-related interventions for July and the first part of August 2026 and should have.
Wheelchair Footrest Not Adjusted for Resident With Limited LE ROM
Penalty
Summary
The facility failed to ensure appropriate wheelchair positioning for R11. R11 had a diagnosis of dementia, severe cognitive impairment on MDS assessments, limited ROM in both lower extremities, and was dependent on staff for locomotion in her wheelchair. Her care plan, revised 07/02/2026, instructed staff that she was dependent on staff for locomotion in her wheelchair. During observations on 08/03/2026 and 08/04/2026, R11 was seen sitting in her wheelchair at the dining room table with her feet hovering several inches above the wheelchair footrest. CNA M confirmed on 08/04/2026 that R11's feet did not reach the footrests, and CNA N stated the footrest needed to be adjusted to fit R11 better. On 08/05/2026, Administrative Nurse D also stated the footrest needed to be adjusted to better fit the resident and support her feet. The facility policy for Use of Assistive Devices stated that assistive device use would be based on the resident's needs, as indicated.
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