**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure residents were free of significant medication errors for 1(#78) of 33 residents reviewed in the final sample. The facility failed to ensure Resident #78 received Eliquis as ordered by the physician. This deficient practice resulted in an Immediate Jeopardy situation for Resident #78, a resident with a history of Pulmonary Embolism and Acute Embolism and Thrombus of the Lower Extremity, on [DATE] at 08:00 a.m. when S5LPN discontinued his order for Eliquis without a physician's order. Resident #78 did not receive Eliquis as ordered from [DATE] through [DATE]. Resident #78 was found on [DATE] at 12:00 a.m., lying on the right side of the floor, unresponsive, pulseless and not breathing. The coroner's report read causes of death: Acute Myocardial Infarction vs Pulmonary Embolism; Hypertension' changes of Aging. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. S1NFA and S2DON were notified of the Past Noncompliance Immediate Jeopardy on [DATE] at 3:38 p.m. Findings: Review of the medication Black Box Warning for Eliquis revealed the following, in part: Warning: Premature discontinuation of Eliquis increases the risk of thrombotic events: Premature discontinuation of any oral anticoagulant, including ELIQUIS, increases the risk of thrombotic events. To reduce this risk, consider coverage with another anticoagulant if Eliquis is discontinued for a reason other than Pathological bleeding or completion of a course of therapy. Eliquis is indicated for the treatment of DVT and PE, and for the reduction in the risk of recurrent DVT and PE following initial therapy. Review of the clinical record revealed Resident #78 was admitted to the facility [DATE] with diagnoses which included, Acute Embolism and Thrombosis of Right Distal Lower Extremity and Pulmonary Embolism without Acute cor Pulmonale. Review of the Care Plan dated [DATE] for Resident #78 revealed the following, in part: Problem: I am at risk for deep vein thrombosis. Interventions: Administer my anticoagulant as ordered . Review of the Hospital Discharge orders, dated [DATE] revealed in part, the following: Eliquis 5 mg tablet for a clot in the lung, take 2 tablets by mouth 2 times daily for 30 days, then 1 tablet (5 mg total) 2 times daily on [DATE]. Review of the Physician Orders dated [DATE] for Resident #78 revealed on [DATE] at 8:00 p.m. an order was implemented for Eliquis 5 mg tablet by mouth twice daily and on [DATE], the Eliquis was discontinued. Further review revealed no order to discontinue Eliquis 5 mg tablet by mouth twice daily. Review of the Medication Administration Record dated [DATE] for Resident #78 revealed Eliquis 5 mg tablet by mouth twice daily was not on the MAR to be administered from [DATE] to [DATE] per physician orders. Review of the nurse's note dated [DATE] revealed the following: [DATE] at 12:00 a.m.: Summons to room by CNA when arrived observed resident lying on right side on floor nonresponsive. No pulse, no breathing noted. Charge nurse verified code status as DNR. Notified Acadian who came out and did an EKG which showed asystole. Acadian paramedics advised to leave body on floor until coroner review body. Review of the Coroner's Report for Resident #78 revealed the following, in part: I, Coroner, certify the following report of death: Date and time of death: [DATE] at 00:15 Causes of death: Acute Myocardial Infarction vs Pulmonary Embolism; Hypertension' changes of Aging. On [DATE] at 10:21 a.m., a telephone interview was conducted with S14NP. She stated she would not discontinue Resident #78's Eliquis due to his history of Pulmonary Embolism and an active blood clot. She stated Resident #78 not receiving the Eliquis for ten days could have contributed to his death. She stated Resident #78 did not have any procedures that would have caused a physician to hold the Eliquis for a period of time. On [DATE] at 10:35 a.m., an interview was conducted with S2DON. She stated Resident #78 had a history of a cerebrovascular accident, traumatic brain injury, and was admitted to the facility in [DATE] with a blood clot. She stated S5LPN discontinued Resident #78's Eliquis on [DATE] without a physician's order. On [DATE] at 12:36 p.m., a telephone interview was conducted with S5LPN. She confirmed she discontinued Resident #78's Eliquis, but did not know why. She stated she believed Resident #78 had an upcoming procedure and that was why she discontinued the Eliquis. On [DATE] at 12:45 p.m., an interview was conducted with S2DON. She stated when a medication order was modified or discontinued the nurse should document a note in the electronic chart stating who discontinued or modified the medication and why. She reviewed Resident #78's clinical record and confirmed there was no documentation or order to discontinue Eliquis. She stated if there was no order to discontinue Resident #78's Eliquis, then the medication should not have been stopped. She confirmed S5LPN discontinued Resident #78's Eliquis on [DATE] without a physician's order. She confirmed Eliquis was removed from the MAR on [DATE] after the order was discontinued and there was no documentation Resident #78 received the medication from [DATE] through [DATE] when Resident #78 expired. On [DATE] at 5:20 p.m., an interview was conducted with S13LPN. She explained S2DON or the floor nurse would place orders in the resident's chart and then initiate the order in the electronic system. She stated each day she would review the telephone order slips or order discontinuation forms from the previous day to ensure the orders were implemented accurately. She confirmed if there was not an order to discontinue a medication, she would not have known to review it for accuracy. She reviewed Resident #78's physician's orders and confirmed Eliquis 5 mg twice a day was discontinued on [DATE] at 3:52 p.m., by S5LPN, without a physician's order. S13LPN stated beginning the last week of each month, administrative staff should print reports and verify all orders in the resident's charts were accurate. She stated the facility would not have known Resident #78's Eliquis was discontinued without an order until the end of the month of [DATE]. She confirmed the facility did not include Resident #78's chart check in the [DATE] review because he had already expired. She stated she received in-service training on the new chart check process and verifying order entry and discontinuation during the end of [DATE] through May because the facility switched of computer systems. On [DATE] at 11:00 a.m., an interview was conducted with S2DON. She stated she was not aware Resident #78's Eliquis was discontinued without a physician's order until yesterday. She stated the facility implemented a new computer system on [DATE]. She stated with the implementation of the new system, the facility implemented corrective actions to ensure orders accuracy. She stated the new process was all current resident's orders would be verified against written orders and checked for accuracy. She stated all nursing staff were in-serviced on order entry and discontinuation in the new computer system on [DATE]. She stated on [DATE], after surveyors entered the facility, nursing staff compared the resident's paper MARs to the orders in the new computer system and to the Medication Card instructions during med passes to ensure proper administration of medications as ordered. She stated since [DATE], each morning, Data Entry compared carbon copies of new written orders and a report of newly discontinued orders generated from the computer data to ensure residents received medications as ordered. She stated the facility reeducated nurses on the importance of entering medication orders into the electronic record and comparing the medication cards to the eMAR during med pass for order accuracy on [DATE]. She stated going forward the facility will have e-signature available for physician use to sign orders. She stated on [DATE] education and ongoing completion of order validation began and continues to date with no issues identified. S2DON read the written plan of removal, which stated substantial compliance was attained and maintained effective [DATE]. She stated the facility was in complete compliance on [DATE]. The facility has implemented the following actions to correct the deficient practice: On [DATE] the following plan of correction was completed and included the following: Issue/Concern: Administer anticoagulant medications as ordered. (J.[NAME] documentation of Eliquis being administered as ordered incomplete per review of the MAR beginning [DATE]- [DATE]) Areas/Systems/Programs Affected: - On admission a data entry error into computer system Physician's Order module for Eliquis frequency and a D/C of Eliquis on [DATE] resulted in prior non-compliance for no or inaccurate electronic documentation of administration of Eliquis to J. [NAME]. - An audit of Eliquis supply ordered and obtained from Pharmacy from [DATE] - [DATE] compared to remaining supply of Eliquis indicates facility provided the 140 tabs required to administer Eliquis as ordered during facility stay ([DATE] - [DATE]). Plan of Correction: The following tasks/ methods were completed in to ensure medications administered as ordered by the facility: 1. Administrative nursing staff were trained by the new computer system liaison on order entry including discontinued orders on [DATE] with competencies dated [DATE]. 2. From [DATE] - [DATE], Data Entry nurse reviewed current and newly received orders in computer system for accuracy and no issues were noted. 3. From [DATE] - [DATE], data entry nurse completed audits of carbon copies of newly written orders including newly discontinued orders to ensure current medications ordered are firing properly ensure proper administration of medications. 4. Facility completed chart audits of current resident's physician's orders and compared them to orders entered into computer system electronic order module [DATE] to [DATE] to ensure current medications ordered are firing properly in the eMAR for order validation to ensure proper administration of medications as ordered. Reviewing nurse signed/dated [DATE]'s monthly physician's orders and they were sent to MD for review and signature then filed on resident's chart. 5. Administrative nurses and Regional QI nurses trained staff nurses on order entry including discontinuing orders on [DATE]. 6. On [DATE], facility again completed chart audits of current resident's physician's orders and compared the orders in prior computer system to ensure current medications ordered are firing properly in eMAR for order validation to ensure proper administration of medications as ordered. Reviewing nurse signed/dated [DATE]'s monthly physician's orders and they were sent to MD for review and signature then filed on resident's chart. 7. On [DATE], data migration of orders from the prior computer system into the new system completed. 8. From [DATE] to [DATE], Facility dual entered newly written orders including newly discontinued orders into both computer systems to ensure current medications ordered fired properly in eMAR for order validation to ensure proper administration of medications as ordered. 9. From [DATE] to [DATE], facility completed chart audits of current resident's physician's orders, newly received orders, and newly discontinued orders compared to orders entered into the new system and the prior system's electronic orders module to ensure current medications ordered fired properly in eMAR for order validation to ensure prop administration of medications as ordered. 10. On [DATE], nursing staff compared prior system paper MARs/TARs to new system eMAR/eTAR to Medication Card instructions during med passes for order validation to ensure proper administration of medications as ordered. 11. Since [DATE], each morning, Data Entry has compared carbon copies of newly written orders and a report of newly discontinued orders generated from the new system data validation to ensure residents continued to receive medications as ordered. 12. On [DATE], Data Entry re-validated newly entered and newly discontinued orders in the new system to ensure medications are firing to system's eMAR properly from [DATE] - [DATE] for proper documentation of administration as ordered with no issues noted. 13. The following steps will be completed for order validation to ensure proper administration of medications as ordered: - Data entry of medication orders for new admissions will be confirmed by 2 nurses - Monday - Friday, Data Entry or designee will compare carbon copies of newly written orders and a report of newly discontinued orders generated from the new system to the current orders in the system - These carbon copies of newly received orders and reports of newly discontinued orders will be retained to be reviewed again during end of month order validation 14. [DATE], Data Entry re-educated by the DON on the order validation process to ensure administration of medications as ordered. 15. On [DATE], facility re-educated nurses by ADON on the importance of entering medications orders into the new system and comparing the medication cards to the eMAR during med pass for order validation to ensure proper administration of medications as ordered. 16. Going forward facility will have e-signature available for physician use to sign orders and the facility does not currently use agency staff and has not used them since the last day in [DATE]. There is no plan to reinstitute agency staff at this time. 17. The DON or designee will monitor by reviewing completion of order validation findings twice weekly on a random sample of 10 residents to ensure continued compliance for 6 weeks and randomly monthly thereafter. 18. All new nursing staff will be trained by staff development nurse or designee on administering medication as ordered during orientation prior to independent medication administration. 19. On [DATE] education and ongoing completion of order validation began and continues to date with no issues identified, it is the facilities belief that substantial compliance was attained and maintained effective [DATE].