**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to follow its procedure for ensuring an order had been received after laboratory testing for 1 of 3 residents (R1) reviewed for Coumadin/Warfarin (an anticoagulant) use, this failure resulted in seven missed doses and sub-optimal lab results which placed R1 at risk for embolism formation (an abnormal clot in the circulatory system). This resulted in an Immediate Jeopardy (IJ) for R1. The IJ began on 11/21/22, when a licensed practical nurse (LPN)-A failed to follow a prompt in R1's Medication Administration Record (MAR) to contact the clinic if an order for Coumadin dosing had not been received after laboratory test results had been sent. Additionally, on six subsequent days, staff failed to respond to further prompts to take action if no Coumadin order was found in the MAR. The facility administrator and director of nursing were notified of the IJ on 12/1/22, at 1:51 p.m. The IJ was removed and the deficient practice was corrected on 11/28/22, prior to the start of the survey, therefore, was issued at Past Non-compliance. Findings include: According to an admission Minimum Data Set (MDS) assessment dated [DATE], R1 received anticoagulant medication for seven days of a seven day look-back period. R1 had a history of having suffered a pulmonary embolism (clot in the lung) and atrial fibrillation (irregular atrial heart beat that can result in clot formation), heart failure, diabetes mellitus and multiple sclerosis among other co-morbidities. According to a hospital Discharge summary dated [DATE], R1 entered the hospital on [DATE], due to shortness of breath which was caused by pneumonia. Upon admission, R1 was discovered to have an elevated international normalized ratio test (INR- a test to check blood clotting time) at 3.8 (with an optimal goal of 2-3) which later rose to 5.1 and then 5.9 attributed to his infectious process, and R1's Coumadin was stopped while in the hospital. After receiving treatment for his pneumonia, R1 was discharged back to the facility on [DATE]. At that time his Coumadin order was being held (this is an order to temporarily stop administering medication) and was to continue to be on-hold for at least two days from 11/18/22 until 11/21/22 when R1's INR level was to be re-checked for adjustment dosing at the facility. According to R1's November 2022 MAR, the facility documented the following orders: -Coumadin Tablet (Warfarin Sodium) Give 2 milligrams (mg) by mouth at bedtime every Mon, Wed, Fri related to SINGLE SUBSEGMENTAL PULMONARY EMBOLISM WITHOUT ACUTE CORPULMONALE until 11/22/2022 (then discontinued 11/18/22). -INR draw (complete lab work) in the morning-Start Date-11/21/2022. This was initialed as having been completed by a registered nurse (RN)-A. -Ensure Coumadin orders received from anticoag clinic in the morning until 11/21/2022. 23:59 (11:59 p.m.)-Start Date-11/21/2022. This was initialed as having been completed by LPN-A. -Anticoagulation Therapy: If there is no Coumadin scheduled for HS (bedtime) notify nurse to check Coumadin orders immediately!-Start Date-11/18/2022. This was initialed as having been completed each evening between 11/18/22 and 11/27/22 by four different staff on different days. A facility medication error report dated 11/28/22, indicated no orders had been received for Coumadin after R1's INR had been drawn on 11/21/22, and INR results [of 1.7] were faxed to the anticoagulation clinic. The report indicated the clinic did not receive the fax. Furthermore, the error report indicated a nurse had not followed up on the missing order and medication aides believed the medication to be on-hold. The facility documented missed doses from 11/21/22 through 11/28/22. R1's anticoagulation clinic note dated 11/28/22, indicated R1's INR had been 5.9 on 11/18/22, and on 11/28/22, R1's INR was 1.0. The clinic ordered Coumadin dosing of 5 mg daily and to retest INR on 12/1/22. In the meantime, the clinic recommended the facility monitor R1 for signs and symptoms of pulmonary embolism or stroke. During an interview on 11/30/2022 at 1:14 p.m. a trained medication aide (TMA)-A stated the facility process for ensuring Coumadin orders did not get missed included written prompts in the MAR for the person administering medications to check for a newly ordered dose following every lab day, and if orders were not found, the nurse on duty was notified of a need for those orders. TMA-A stated on 11/21/22 she notified LPN-A that R1 did not have a Coumadin order. TMA-A stated she was told by LPN-A R1's Coumadin was on hold. TMA-A then said she recalled two days later she worked again and did not see an order and reported again to LPN-A there was no Coumadin order for R1, and ask if there should be anything else. TMA-A stated she was told by LPN-A she had done what she was supposed to do by reporting it, but that the Coumadin was still on hold. TMA-A stated she did not see anything in the MAR that indicated Coumadin was on-hold. During an interview on 11/30/22, 1:34 p.m. RN-A stated the facility process for ensuring continuity of Coumadin dosing was for lab orders to be transcribed into the resident chart, then a copy placed in a lab book/calendar for the nurses who check the labs. After the lab results were obtained, a form was to be filled out with the resident information, the current dose and the lab results. The form was then faxed to the anticoagulation unit then placed in the resident's medical record and the facility would await orders for a new dose. Additionally, the facility placed a prompt in the MAR for the nurse on duty the day labs were drawn, to contact the coagulation clinic if no new orders had been received by the evening shift when the Coumadin was usually scheduled to be given. An additional fail safe prompt was also placed in the MAR for the medication administration staff person to notify the nurse on-duty if no order for Coumadin was found. RN-A stated she had been the nurse to obtain and process R1's INR results on 11/21/22. RN-A stated she had faxed the results to the coagulation unit as usual, and signed R1's MAR to indicate the task had been completed. RN-A said she also placed a copy of the completed lab form in the lab book to show the task had been completed. RN-A stated the MAR did not indicate R1's Coumadin was on-hold and a nurse would have had to review the medical record to find that order. RN-A stated she did not know what had happened to cause R1's missed doses, but said they became aware of the problem when the anticoagulant clinic called the facility on 11/28/22, saying they had not received the fax she had sent on 11/21/22. During an interview on 11/30/22, at 2:15 p.m. LPN-A stated he was not able to recall anything regarding R1's Coumadin orders; however, LPN-A stated there would have been a prompt in the MAR to check for Coumadin orders and contact anticoagulation clinic if no orders. LPN-A stated he must have signed the MAR, but did not remember. LPN-A stated he probably would have signed the MAR if he had called the clinic even if he had not yet received the order. LPN-A stated he believed it would say in the MAR if a medication was on-hold, but he could not remember if this was the case with R1's orders. LPN-A stated he could not remember if a TMA had talked to him about R1's order, but said, usually the TMA's come and say if they don't have an order. LPN-A stated the facility had contacted him after finding out about the missing doses, and had reviewed the concerns. LPN-A stated he had not been back to the facility since that time to do further education. During an interview on 11/30/22, at 2:39 p.m. the facility director of nursing (DON) stated the facility had a process in place with two checks to be completed on the day of an INR lab. R1 had come back from the hospital with his previous coumadin orders discontinued, and to stay on-hold until a follow-up INR had been drawn on 11/21/22. DON stated the nurse on duty that day [LPN-A] failed to ensure orders were in place after the INR was drawn. DON stated LPN-A had not worked since 11/28/22, but she had called him to investigate the cause of the incident, but LPN-A unfortunately could not tell me. DON stated LPN-A acknowledged the incident and was provided education regarding the proper procedure. The DON stated the facility immediately initiated a quality initiative, auditing charts for other errors, and updating their procedure to include an additional note in the MAR whenever a medication is truly on-hold, and when the stop date will be for that hold order. A text message was sent to all nurses and TMA's regarding a concern with missing coumadin orders, and to check their email, and do additional training. All nurses and TMA's were required to do training before returning to their next scheduled shift. DON stated LPN-A would receive the same training, and she would be meeting with him on 12/2/22, when he returned to work. Additionally, DON stated the facility had ordered a new fax machine that could request a confirmation report. R1's primary physician was notified, the medical director (MD)-A was notified and monitoring of R1's condition was put in place until the INR returned to his goal range. A form titled INR Report/Nursing Home Fax dated 12/2021 indicated the facility was to provide the patient name, date of birth and date of the test, along with results and to phone or fax the information. These numbers were provided. The bottom of the form included the following statement, please contact the anticoagulation clinic if you do not receive Warfarin dosing instructions by 4:00 p.m. A policy from the facility's contracted pharmacy titled Medication Administration-general guidelines, dated 4/1/19, indicated, the MAR should contain supplemental information to help assure accurate dosing. documentation of the un-administered dose is done as instructed by the procedures for the use of the eMAR (electronic medication administration record) system. An explanatory note is entered. If a pre-established number of consecutive doses of a vital medication are withheld, refused or not available the physician is notified. The facility provided a document dated 11/28/22, titled Additional Coumadin/Warfarin Procedures. The document listed the following additions: 1. Nursing will make a note on the Treatment Administration Record (TAR) to ensure coumadin orders are received from the anticoagulation clinic which will be scheduled the same day the INR level is drawn. 2. During admissions, nursing will make a note on the Medication Administration Record (MAR) that states, Anticoagulation Therapy: if there is no Coumadin scheduled for HS (bedtime) notify nurse to check Coumadin orders immediately! This task will appear daily which the Trained Medication Aid (TMA) needs to sign off on. 3. When a coumadin order is placed on hole, notation on the MAR will be made for the specific duration of the hold. This is done to alert TMA staff that there is an active order, which is currently on hold. The Past Non-Compliance IJ began on 11/21/22. The IJ was removed, and the deficient practice was corrected on 11/28/22, when an order for Coumadin was initiated, R1 was seen by a medical provider and the facility immediately created an performance improvement plan that included the following actions: additions to their Coumadin/Warfarin administration procedure, notifications to all nurses and TMA's of the changes, training assignments on avoiding significant medication errors, verbal education to LPN-A and audits of the MAR for all other residents receiving Coumadin to ensure compliance.