Health inspection·July 19, 2024

F770 §483.50(a) Laboratory Services. §483.50(a)(1) The facility must provide or obtain laboratory services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services. On 5/24/2024, an unannounced visit was made to the facility to investigate a facility reported incident regarding quality of care. The facility failed to ensure that Resident 1, who had a diagnosis of paroxysmal atrial fibrillation (A-fib- an irregular, rapid heart rhythm that commonly causes poor blood flow) and was prescribed Coumadin (also known as Warfarin- a medication used to prevent blood clots [gel-like clumps of blood] from developing), was provided with the needed laboratory services when on 5/16/2024, a physician order for the laboratory draw of Prothrombin Time with an International Normalized Ratio (PT/ INR- a laboratory test that takes a measurement of the time taken for blood to clot; lab results are needed for the attending physician to determine what dose of Coumadin a resident should take) was not done for Resident 1. It was not until 5/29/2024 (13 days after physician’s order) that the facility realized that Resident 1’s ordered PT/INR for 5/16/2024 was not completed. As a result, Resident 1 did not received Coumadin from 5/18/2024 to 5/29/2024 which placed Resident 1 at risk for life threatening complications such as blood clots that can lead to stroke (serious life-threatening medical condition that happens when the blood supply to part of the brain is cut off), heart failure and death. A review of Resident 1’s Admission Record dated 5/15/2024, indicated the facility originally admitted Resident 1 on 4/30/2024 and re-admitted Resident 1 on 5/15/2024. Resident 1’s diagnoses included paroxysmal atrial fibrillation, cerebral infarction (stroke- damage to tissues in the brain due to a loss of oxygen to the area), hemiplegia (one-sided muscle paralysis [inability to move] or weakness) and hemiparesis (the weakness or inability to move one side of the body) following cerebral infarction. A review of Resident 1’s Minimum Data Set (MDS - a comprehensive assessment and screening tool) dated 5/20/2024, indicated Resident 1 had moderate cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS further indicated that Resident 1 required maximum assistance from staff with oral hygiene, toileting hygiene, showering or bathing, dressing and personal hygiene. A review of Resident 1’s Physician Order dated 5/15/2024 indicated the following: 1. An order for Coumadin oral tablet two (2) milligrams (mg- unit of measurement) in the evening for paroxysmal A-fib for two (2) days. 2. An order for laboratory services for a PT/INR to be drawn on 5/16/2024. A review of Resident 1’s Medication Administration Record (MAR- a report detailing the medications administered to a resident) dated May 2024, indicated Resident 1 received Coumadin two (2) mg on 5/16/2024 at 5:00 p.m. and 5/17/2024 at 5:00 p.m. A review of Resident 1’s laboratory test request form dated 5/16/2024, indicated a PT/INR was scheduled to be drawn on 5/16/2024. A note on Resident 1’s laboratory test request form indicated “Transferred”. A review of the facility census dated 5/15/2024 indicated Resident 1 was in Room A. A review of the facility census dated 5/16/2024 indicated Resident 1 was moved to Room B. A review of Resident 1’s Change of Condition (COC- a sudden deviation from a resident’s health status), dated 5/29/2024, indicated Resident 1’s last day of Coumadin two mg was given on 5/17/2024 and primary care provider was informed. During an interview on 6/5/2024 at 1:40 p.m. with Registered Nurse Supervisor 1 (RNS 1), RNS 1 stated that Resident 1 did not receive any Coumadin from 5/18/2024 to 5/29/2024. RNS 1 stated that on 5/29/2024, RNS 1 was informed by Licensed Vocational Nurse 1 (LVN 1) that during a chart review, LVN 1 noted that Resident 1 did not have the physician ordered PT/INR completed on 5/16/2024. RNS 1 stated that Resident 1’s laboratory test request form dated 5/16/2024 indicated that Resident 1 had been “transferred”, however, RNS 1 stated that Resident 1 was only transferred within the facility from Room A to Room B. RNS 1 stated that Resident 1 was not transferred out of the facility. RNS 1 further stated that upon learning that Resident 1 did not have an ordered dose of Coumadin as a result of not having Resident 1’s PT/INR lab drawn, RNS 1 immediately informed Resident 1’s physician. RNS 1 stated that Resident 1’s physician ordered for a stat (a medical abbreviation for urgent or rush) PT/INR, stat electrocardiogram (EKG- a diagnostic test that measures the electrical impulses of your heart to check for signs of heart disease) and to monitor Resident 1’s vital signs (measurements of the body’s most basic functions which include body temperature, pulse rate [heart rate], respiration rate [rate of breathing], and blood pressure [ the force of your blood pushing against the walls of your arteries]) every four (4) hours. RNS 1 stated that on 5/30/2024 RNS 1 informed the doctor of the results of the PT/INR drawn on 5/29/2024. RNS 1 stated that the doctor ordered to administer Coumadin 3.5 mg to Resident 1. During a follow-up interview with RNS 1 on 6/5/2024 at 1:50 p.m., RNS 1 stated that the licensed nurses should have followed up on why Resident 1 remained off Coumadin and why Resident 1’s PT/INR for 5/16 was not completed. A review of Resident 1’s Physician Orders dated 5/29/2024 indicated the following: 1. An order for Stat PT/INR 2. An order for Stat EKG A review of Resident 1’s PT/INR result dated 5/29/2024 indicated, a result of: 1. PT result of 10.6 seconds (reference range is less than 14.5 seconds) 2. INR result of 0.94 (reference range is 0.9 to 1.1, with a therapeutic range of 2.0 to 3.0 for residents with diagnosis of atrial fibrillation. A review of Resident 1’s Physician Orders dated 5/30/2024 indicated the following: 1. An order for Coumadin 3.5 mg in the evening for paroxysmal atrial fibrillation. 2. An order for PT/INR to be drawn on 5/31/2024. A review of Resident 1’s MAR dated 5/30/2024 indicated, Resident 1 was administered Coumadin 3.5 mg at 5:00 p.m. A review of Resident 1’s PT/INR result dated 5/31/2024 indicated, a result of: 1. PT result of 10.3 seconds 2. INR result of 0.91 seconds During an interview on 6/5/2024 at 2:30 p.m. with LVN 1, LVN 1 stated that on 5/29/2024 LVN 1 noted that Resident 1’s PT/INR ordered dated 5/16/2024 did not have a result. LVN 1 stated that LVN 1 informed RNS 1 who then immediately informed Resident 1’s physician on 5/29/2024. During an interview and concurrent record review on 6/5/2024 at 4:30 p.m. with Registered Nurse Supervisor 2 (RNS 2), reviewed Resident 1’s laboratory test request form dated 5/16/2024 for Resident 1’s PT/INR. RNS 2 stated that when the phlebotomist (medical professional who draws blood and collects samples of the residents for laboratory tests) comes to the facility, the phlebotomist will take the laboratory request form and obtain the physician ordered laboratory test. RNS 2 stated that Resident 1’s laboratory test request form dated 5/16/2024 had “transferred” written on the form. During an interview with Resident 1’s primary physician (Medical Doctor 1[MD 1]) on 6/6/2024 at 1:20 p.m., MD 1 stated that Resident 1 is being prescribed Coumadin due to Resident 1’s history of A-fib. MD 1 stated that Resident 1 was re-admitted to the facility on 5/15/2024 and that MD 1 ordered Coumadin two mg for two days and for a PT/INR laboratory draw to be done on 5/16/2024. MD 1 stated that it was important to have Resident 1’s PT/INR lab drawn on 5/16/2024 in order for MD 1 to decide on the appropriate dose of Coumadin needed for Resident 1. MD 1 stated that he was not aware Resident 1 did not receive Coumadin from 5/18/2024 to 5/29/2024 until MD 1 was informed on 5/29/2024 by the nursing staff (unable to recall specifically who). MD 1 stated that MD 1 immediately ordered for a stat PT/INR, stat EKG, and monitoring including vital signs of Resident 1. MD 1 stated that it is important for Resident 1 to be administered Coumadin because Resident 1 is at an increased risk of developing a blood clot while not taking Coumadin. MD 1 further stated that he had spoken to the facility staff to put a system in place to prevent recurrence. During an interview with the Director of Nursing (DON) on 6/6/2024 at 1:53 p.m., the DON stated that on 5/16/2024 Resident 1 was transferred from Room A to Room B. The DON stated the assigned licensed nurse should have communicated to the receiving licensed nurse all of Resident 1’s care needs including Resident 1’s laboratory test request form dated 5/16/2024 for PT/INR. The DON stated Resident 1 had not been prescribed Coumadin from 5/18/2024 to 5/29/2024 as a result of Resident 1’s ordered PT/INR for 5/16/2024 not being done. The DON stated that Resident 1 was placed at risk for heart problems and had an increased risk of developing a blood clot including a stroke because the PT/INR was not drawn on 5/16/2024 and did not receive Coumadin for 12 days. A review of the facility’s policy and procedure (P&P) titled “Lab Work, Ordering and Reporting”, not dated, indicated, it is the policy of this facility to obtain lab work and report lab results in a manner to ensure resident healthcare needs are met and addressed timely. The facility failed to ensure that Resident 1, who had a diagnosis of A-fib and was prescribed Coumadin, was provided with the needed laboratory services when on 5/16/2024, a physician order for the laboratory draw of PT/ INR was not done for Resident 1. It was not until 5/29/2024 (13 days after physician’s order) that the facility realized that Resident 1’s ordered PT/INR for 5/16/2024 was not completed. As a result, Resident 1 did not received Coumadin from 5/18/2024 to 5/29/2024 which placed Resident 1 at risk for life threatening complications such as blood clots that can lead to stroke, heart failure and death. The above violations had a direct relationship to the health, safety, or security of Resident 1.