**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, hospital record review, facility record review, staff interview, the facility failed to respond appropriately to an INR level below the target range for treatment for one resident reviewed and failed to appropriately monitor another resident's PT/INR as directed by the physician as a means to assure individual therapeutic levels. (Resident #1 and Resident #4) The facility identified a census of 22 residents. Findings include: 1. A Significant Change Minimum Data Set (MDS) assessment form dated 10/10/22 for Resident #1 documented diagnoses that included: systolic and diastolic heart failure (HF), abnormal anti-coagulant profile, atrial fibrillation (AF), respiratory failure with hypoxia and a duodenal ulcer with perforation and hemorrhage. The assessment documented the resident received an anti-coagulant (blood thinner) 3 days out of the past 7 during the look back period. A Physician's Orders with current orders as of 8/3/22 documented that the Resident#1 had a history of acute duodenal ulcer with hemorrhage and perforation (bleeding in the belly), aortic valve stenosis (clogged heart valves), gastrointestinal hemorrhage (bleeding in the intestine, and stomach). A Care Plan with a focus area initiated on 2/9/22 identified the resident as on anticoagulation therapy related to AF. The interventions included the following as dated: a. Labs as ordered. Report abnormal lab results to the MD. (initiated 2/9/22) b. Monitor/document/report to the physician as needed (PRN) signs and symptoms of anti-coagulant complications: lethargy, sudden changes in mental status and/or a significant or sudden change in vital signs. (initiated 2/9/22) A Medication Administration Record (MAR) form dated November 2022 documented a physician's order for warfarin (Coumadin) 1 milligram (mg) by mouth (po) every day (qd). (originated 10/7/22 and discontinued 11/21/22) A Nurse's Note with effective date 11/18/22 at 2:00 p.m. and Created date of 11/25/22 at 10:08 a.m. included the following entry; Late entry: As a therapist worked with the resident, she noticed resident as paler than usual and reported the observation to the resident's daughter who also had been present. The nurse placed a call to the Physician who ordered a lab draw which included an INR (which had been due on 11/21/22). A Lab Results Report form with collection date of 11/18/22 at 4 p.m., received at the lab at 7:10 p.m. and reported at 8:53 p.m. documented the resident's PT (Prothrombin Test Time which measured how long it took for a blood clot to form in the blood sample) level at 18.3 and INR (International Normalized Ratio which measured if a person sustained a blood clotting problem) level at 1.6. The therapeutic range for a patient routinely anticoagulant as 2.0-3.0 and residents with a mechanical prosthetic heart valve as 2.5-3.5. The staff faxed the form to the physician's office but failed to call and address the abnormal lab values to the resident's physician and/or the on call physician. A hospital History and Physical form completed 11/27/22 documented the resident as admitted to the facility on [DATE] at 10:51 p.m. with an intracranial hemorrhage, a cerebral vascular accident (CVA) and precerebral occlusion and with the presence of a prosthetic heart valve. The resident's Certificate of Death filed 12/1/22 documented the resident passed away on 11/23/22 at 5:30 p.m. with the immediate cause of death as a stroke secondary to AF. A Notification to Physician or Family of Change in Resident Health Status policy dated 10/20/21 directed the Care Communities staff to have notified the resident's physician or designee as follows: a. An acute illness or significant change in the resident's physical, mental or psychosocial status (i.e., deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications.) The facility described nursing judgement as an integral part of the skilled care provided in the Care Communities; therefore, staff must have applied such judgment in a case-by-case basis for maintenance of an acceptable nursing practice. Some definitions included the following: b. A need for alteration in a treatment significantly such as a need to stop a form of treatment because of adverse consequences (e.g., an adverse drug reaction), or a need for initiation of a new treatment to have dealt with a problem. 2. An admission MDS assessment form dated 10/24/22 for Resident #4 documented the resident had diagnoses which included: AF and non-Alzheimer's dementia. The MDS documented the resident had been on anti-coagulants 7 of the last 7 days in the look back period. A Care Plan with a focus area initiated on 10/17/22 and revised 10/18/22 identified the resident as on anti-coagulant therapy related to AF. The interventions included the following; a. Labs as ordered. Report abnormal lab results to the physician. (initiated 10/17/22). b. Monitor/document/report to the physician as needed (PRN) signs and symptoms of anti-coagulant complications: lethargy, sudden changes in mental status and/or a significant or sudden change in vital signs. (initiated 10/17/22) A Lab Results Report form collected 11/18/22 at 3:55 p.m., received at the lab at 8:37 p.m. and reported at 8:54 documented the resident's PT at a 20.7 ( abnormal results as indicated by the Orange text on the report) and INR at a 1.8 (abnormal results as indicated by the Orange text on the report), with the therapeutic range for a patient routinely anticoagulated as 2.0-3.0. The Physician order included the following: If on Coumadin 5 mg increase to 5.5 mg and recheck the PT/INR in one (1) week. During an interview 12/13/22 at 1:50 p.m. the Director of Nursing (DON) services indicated when staff faxed information to the physician the facility policy directed the staff to have placed the faxed forms into a binder as a reminder to follow up with the physician accordingly. The nurse, in this case, inadvertently placed the faxed form in the resident's medical record so the lab draw had been missed. During this investigation the mistake had been identified to the facility, the facility staff informed the resident's physician and a new order received to re-check the resident's PT/INR on 12/2/22. An Immediate Jeopardy (IJ) was identified on 12/14/22 and the facility was notified of the IJ at 11:30 a.m. that day. The IJ was removed later that day when the facility developed and implemented the following corrective action plan: 1. PT/INR will no longer be drawn on Fridays, if possible. If an emergency lab needs to be drawn on a Friday, the results will be called in to the on-call provider, even if they are not at a critical level. 2. Anticoagulant book implemented in order to better manage Coumadin tracking. 3. Process implementation of PT/INR draw date changes and physician notification of non critical labs drawn on Fridays. 4. Process implementation of anticoagulant book and fax process. 5 Staff educated on change in PT/INR draw guidance. 6 Staff educated on fax process The scope and severity level of the IJ deficiency was lowered from an J to an D at the time of the survey due to the need for continued monitoring after the facility completed the above removal plan.