Health inspection·April 3, 2024

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident was free of significant medication errors for 1 of 3 residents (R2) reviewed for medications. Residents Affected - Few The findings include: R2's facesheet showed he was admitted to the facility on [DATE], with diagnoses to include Parkinson's Disease, Type 2 Diabetes, hypertension, chronic kidney disease, Paroxysmal atrial fibrillation, and presence of prosthetic heart valve. R2's care plan, with problem onset 9/4/2017, showed, [R2] has alteration in blood clotting related to use of anticoagulant medications . Administer anticoagulants per physician orders . labs as ordered. Inform physician for dosage changes . R2's March eMAR (electronic Medication Administration Record) showed his anticoagulant (blood thinner) medication was administered on 3/10/24, and then not again until 3/19/24 (8 days without receiving his anticoagulant medication). R2's 3/18/24 nursing note showed, Writer notified on call Nurse Practitioner that resident has no order for Coumadin in [the electronic health record] and does not seem to have had Coumadin since 3/10/24 . order to recheck INR in the morning and have NP address results. Unit Manager notified. Resident notified. POA (Power of Attorney) notification endorsed to morning shift . R2's 3/19/24 nursing note showed, Call placed to POA (Power of Attorney) this morning and informed of resident missing Coumadin. Told that on call Nurse Practitioner was called last night and PT/INR was drawn this morning. I told POA that I would call her with the results of the PT/INR and orders that were received. Answered all question and informed her vital signs would be taken every shift for 72 hours. On 4/2/24 at 12:56 PM, V6 said when she was assigned to work R2's hall, she noticed he did not have an order for Coumadin. V6 said she knew R2 was on Coumadin because she has worked at the facility for 7 years and is pretty familiar with the resident's medications. V6 said when Coumadin orders are put into the system, they have a stop date that coincides with the resident's lab draw that monitors the residents blood. V6 said the nurse would report the results of the resident's lab to the nurse practitioner and get a new order for Coumadin at that time. V6 said the new order was not entered into the system, so the Coumadin was not given. V6 said it is important for R2 to receive Coumadin so his artificial heart valve functions properly. Page 1 of 2 145563 145563 04/03/2024 The Citadel at Saint Anne Place 4405 Highcrest Road Rockford, IL 61107

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 4/2/24 at 12:40 PM, V3 (Unit Nurse Manager) said R2 takes anticoagulants because he has an artificial heart valve. V3 said R2 had a medication error. V3 said everything was brought forward except the order for R2's Coumadin. The facility's policy and procedure reviewed 1/2024 showed, . Procedure: Anticoagulant . Treatment/Management: A. The physician will prescribe anticoagulation therapy (for example, low molecular weight heparin or warfarin [Coumadin]) appropriately, in accordance with recognized guidelines . Monitoring and Follow-Up: A. The physician will order appropriate lab testing to monitor anticoagulant therapy and potential complications; . 1. The associates should use a warfarin flow sheet or comparable monitoring tool to follow trends in anticoagulant dosage and response. 145563 Page 2 of 2