**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident, family, staff interview, Nurse Practitioner, and Medical Doctor interview the facility failed to 1)ensure effective communication amongst the nursing staff and with the provider in order that a resident, who was receiving anticoagulation medication, be sent to the hospital when she first experienced post-operative bleeding to the degree that the bleeding soaked her sheets 2) failed to recognize they should communicate with the physician about anticoagulant medication before continuing to give the anticoagulant medication after the resident was observed bleeding post-operatively 3) failed to identify a need for a higher level of care 4) failed to assess vital signs and 5) failed to perform treatments as ordered. Resident #1 was transported to the emergency room, required a blood transfusion for low hemoglobin, and was admitted to the hospital for two days. This was for one (Resident #1) of three residents reviewed for professional standards. Findings included: Resident #1 was originally admitted to the facility on [DATE] and had a discharge to the hospital on [DATE] with a readmission on [DATE]. Resident #1 had diagnoses of deep vein thrombosis (2019), pulmonary embolism (2019), anemia, and peripheral vascular disease. Deep vein thrombosis is a blood clot that forms in a large vein deep within the body, typically in the lower leg or thigh. A pulmonary embolism is a condition in which one or more arteries in the lungs become blocked by a blood clot. Peripheral vascular disease is a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs. An annual Minimum Data Set assessment dated [DATE] coded Resident #1 as having a Brief Interview for Mental Status assessment of 13 out of 15, indicating she was cognitively intact. Resident #1 was also coded as dependent for rolling from left and right in bed and transfers. Resident #1 was coded as receiving an anticoagulant. Review of the electronic medical record revealed Resident #1 had recent micrographically oriented histographic surgery (Mohs) surgery on her left lower extremity for non-melanoma skin cancer on 10/17/2024. [NAME] surgery is a surgical procedure that removes skin cancer lesions by gradually removing thin layers of tissue and examining each layer under a microscope for cancer cells. Wound care instructions from the dermatologist were as follows: After 48 hours, remove the bandage. Clean the wound with ½ tap water and ½ peroxide and apply Vaseline (or prescribed antibiotic ointment). After [the] first 48 hours you may shower, and the wound site can get wet unless otherwise instructed. Cover the wound with a non-stick gauze pad (Telfa) and micropore paper tape. A.Resident #1 had a physician's order, initiated on 7/21/2024, for 5 milligrams (mg) Eliquis to be administered by mouth two times a day for blood thinner with monitoring for bleeding and bruising. Documentation on the care plan last reviewed on 10/8/2024 revealed Resident #1 had a focus area for alteration in hematological status relative to anemia, anticoagulant side effects and thrombosis. Resident #1 had an additional focus area for anticoagulant therapy for her use of Eliquis. Some of the care plan interventions were to monitor for side effects of anemia and signs/symptoms of anticoagulant complications. Documentation in the nursing progress notes dated 10/22/2024 at 11:08 PM written by Nurse #3 revealed, This writer walked in resident room to administer medicine and upon walking in resident room her bedsheet had blood and upon checking the dressing on left leg was saturated with blood. This writer cleaned the area on left leg following the instructions on the TAR (treatment administration record) for dressing change and applied gauze, ABD (abdominal) pad and applied pressure and wrapped with kerlix to stop bleeding, which was controlled at the moment. (An ABD pad is a gauze dressing used to absorb fluid from large or heavily draining wounds.) Minutes later going back to check on resident, the dressing was saturated again. MD (medical doctor) on call was notified and gave orders to give Bumex 2 mg and rewrap the wound and apply pressure and monitor, the resident was notified, and stated she wants to go to ED (emergency department) for evaluation. (Bumex is used to treat fluid retention (edema) and high blood pressure.) MD was called back and notified of resident request, non-emergency transport was called, resident transferred to [Hospital name] ED. Son [Name], daughter [Name] and DON (Director of Nursing) notified. An interview was conducted with Resident #1 on an initial tour on 11/14/2024 at 9:36 AM and again at 10:39 AM. Resident #1 provided the following information. Resident #1 revealed she had told Nurse #4, the assigned nurse for the evening shift, to not come into her room anymore. Resident #1 had surgery on her leg for skin cancer and when it was time to change the bandage, Nurse #3 came to change the bandage. Resident #1 had never seen or met Nurse #3 before. Resident #1 revealed Nurse #3 began to change the bandage on her leg, she ripped it off quickly, and it began to bleed. Resident #1 explained she received a medication that was a blood thinner. Nurse #3 called for assistance from a nurse aide in the hallway, and eventually because the bleeding would not stop, she was sent to the hospital. Resident #1 stated it was very scary in the hospital emergency room because she almost passed out from her blood pressure dropping and had to be given blood. Documentation in the physician's orders revealed Resident #1 had an order initiated on 10/22/2024 at 9:15 PM for 2 mg of Bumex to be administered by mouth one time only for edema. An interview was conducted with Nurse #3 on 11/14/2024 at 3:15 PM. Nurse #3 stated she was not assigned to care for Resident #1 on 10/22/2024 but was asked to come to the hall on which Resident #1 resided because Nurse #4 could not go into the room of Resident #1. Nurse #3 provided the following sequence of events. Nurse #3 was working on the 2:45 PM to 11:15 PM shift on 10/22/2024. After the evening meal Nurse #3 went to the hallway Resident #1 resided to give medications to Resident #1. Nurse #3 prepared the medications for Resident #1 and asked NA #1 to go into the room of Resident #1 with her because she did not know this resident and she was meeting her for the first time. Nurse #3 stated she observed blood on top of the sheet and when she pulled back the sheet, she observed the dressing on the left lower leg of Resident #1 was saturated. Nurse #3 returned to the medication cart, put the medications back into the drawer, locked the medication cart, and went to obtain the treatment cart. Nurse #3 removing the saturated dressing from the lower leg of Resident #1 with gloved hands. Nurse #3 washed her hands, put on another pair of gloves and attempted to stop the bleeding of the wound with gauze, ABD pads and Kerlix. Nurse #3 then followed the wound care orders mixing ½ tap water with ½ hydrogen peroxide, cleaned the wound, applied Vaseline, several nonstick gauze pads, an ABD pad and wrapped with Kerlix again. At that point the bleeding seemed under control. Nurse #3 removed her gloves, washed her hands, and went to obtain the medications for Resident #1. Nurse #3 asked Resident #1 if she wanted to take her Eliquis that evening, explaining it was a blood thinner. Resident #1 agreed to take Eliquis. Nurse #3 then went to Nurse #4 and explained to her about the blood on the sheets and performing the wound care as well as medication administration to Resident #1. Nurse #3 tried to call the first contact on the family list for Resident #1 and was not able to reach him so, she contacted the second family member on the list. Nurse #1 relayed the information to the family of Resident #1 about the bleeding of her leg. Nurse #3 then went back to her hall to take care of the needs of her residents on her hallway. Nurse #3 was unsure how long she was performing nursing duties for her hallway as she had several tasks to perform. As Nurse #3 approached the room of Resident #1, NA #1 came out of the room and told her about the bandage on Resident #1's leg being soaked with blood again. Nurse #3 went to call the on-call physician. Nurse #4 was at the nursing station when Nurse #3 telephoned the on-call physician and handed the phone to Nurse #4 because she knew Resident #1 better than her and could provide more details about the resident. Nurse #4 explained to the on-call physician that Resident #1 had edematous legs. Nurse #3 did not recall if it was explained to the on-call physician about the bloody sheets/dressing and the resident being on Eliquis. Nurse #3 was sure she explained to Nurse #4 about the dressing that was found to have bled through for the second time. The physician ordered Nurse #4 to administer a one-time dose of 2 mg of Bumex and to reinforce the dressing. Nurse #3 went back to Resident #1 and asked her if she wanted the 2 mg of Bumex and the reinforced dressing. Resident #1 stated she wanted to call a family member to ask what to do and after talking with her family she decided she wanted to go out to the hospital. Nurse #3 called the on-call physician back and obtained an order to send Resident #1 to the emergency room. Nurse #3 called for non-emergency transport and prepared the paperwork to send the resident out to the emergency room. Nurse #3 then obtained more supplies to reinforce the dressing but was unable to do so because emergency medical services arrived. Nurse #3 stated Resident #1 was alert and talking prior to leaving and she thought she gave her Tylenol for pain. Nurse #3 stated she did update the family of Resident #1 and called the DON to let her know Resident #1 was sent to the ER. Nurse #3 was interviewed again on 11/18/2024 at 2:57 PM. Nurse #3 could not remember if the leg of Resident #1 was elevated. Nurse #3 stated after changing all of the sheets of Resident #1 after performing wound care, she stayed with Resident #1 to assure her leg wound did not continue to bleed. Nurse #3 stated she told NA #1 that if there was any more bleeding before she returned to check on Resident #1, to come to her hallway to get her. An interview was conducted with Nurse Aide (NA) #1 on 11/14/2024 at 2:03 PM. NA #1 confirmed she was the nurse aide assigned to care for Resident #1 on the 3:00 PM to 11:00 PM shift on 10/22/2024. NA #1 stated she was completing her nursing rounds after the evening meal on 10/22/2024 and when she went into the room of Resident #1 observed her sheets were all bloody. NA #1 reiterated it was a lot of blood. NA #1 stated she went to the nurse assigned to the hall, Nurse #4, and was told by Nurse #4 she was not allowed into the room of Resident #1. Nurse #4 went to get Nurse #3. NA #1 stated that Nurse #3 then came to the room and NA #1 stated she held the leg of Resident #1 as Nurse #3 rewrapped the leg. NA #1 stated she then went back later and observed that the leg of Resident #1 was bleeding again so she went back to Nurse 4, who went to get Nurse #3. NA #1 was unable to give a time frame for the events and those were her only recollections of the events. An interview was conducted with NA #2 on 11/14/2024 at 2:42 PM. NA #2 confirmed she was an orientee assigned to work with NA #1 on 10/22/2024 for the 3:00 PM to 11:00 PM shift. NA #2 recalled that she peeked into the room of Resident #1 and saw the bloody sheets on her bed. NA #2 stated at that time NA #1 was assisting Nurse #3 as she bandaged the leg of Resident #1. NA #2 stated that later she went into the room to check on Resident #1 and Resident #1 was on a video call with a family member. NA #1 explained that the family member requested to see the leg and bed of Resident #1 on the video call, so NA #2 took the phone of Resident #1 and showed the family member the bloody sheets that were soaked through and the bloody bandage of Resident #1. NA #2 revealed the family member stated Resident #1 needed to go to the hospital. NA #2 revealed she knew Nurse #3 had already called the doctor and was not able to get an order to send Resident #1 to the hospital. NA #2 indicated she was unable to give a time frame for any of the events and those were her only recollections of the events as it was a fast-paced evening. An interview was conducted with Nurse #4 on 11/14/2024 at 4:10 PM. Nurse #4 provided the following information. Nurse #4 was assigned to the hallway which Resident #1 resided on 10/22/2024 for the 2:45 PM to 11:15 PM shift. Nurse #4 routinely works on this hall, and it has been her assigned hallway for the last year. Nurse #4 stated on 10/22/2024 she was told by Resident #1 she was to no longer come into her room. Nurse #3 came to the hallway to take care of the nursing needs of Resident #1. Nurse #3 told Nurse #4 the leg of Resident #1 was draining heavy. Nurse #3 did not recall being told anything about blood and only about drainage. Nurse #3 did not see the legs of Resident #1, did not enter the room of Resident #1, and did not talk to the family of Resident #1 on 10/22/2024. Nurse #3 called the on-call physician and Nurse #4 did get on the phone with the on-call physician. Nurse #4 revealed she relayed to the on-call physician that Resident #1 got out of the hospital two or three months ago with swelling in her legs. Nurse #4 confirmed she was aware Resident #1 had recent [NAME] surgery due to lesions on her legs and that Resident #1 was on Eliquis. Nurse #4 reiterated she was not aware of any bleeding but only drainage, so she did not provide the information to the on-call physician about the [NAME] surgery on 10/17/24 or that the resident was on a blood thinner. The physician ordered Nurse #4 to administer a one-time dose of 2 mg of Bumex and to reinforce the dressing, which she passed on to Nurse #3. Nurse #4 stated the family of Resident #1 wanted her to be sent to the emergency room so, Nurse #3 called the physician back and had her sent to the emergency room. An interview was conducted with a family member for Resident #1 on 11/14/2024 at 11:24 AM. The family member revealed he was notified by another family member at approximately 6:30 PM on 11/22/2024 that the facility had called because the leg of Resident #1 was bleeding heavily. The family member noted he had missed a phone call from the facility. The family member revealed he called the facility to find out what was going on but was told the nurse assigned to the hall was unable to come to the phone. The family member stated he waited for a phone call back. The family member stated he was on a video call with Resident #1 when he was shown by one of the nurse aides the bloody sheets and bloody dressing on the leg of Resident #1. The family member stated he was able to see on the video call that both the top and bottom sheet of Resident #1 was saturated with blood. The family member stated he took pictures of the bloody sheets with his phone and recorded the time to be 9:36 PM. The family member stated Resident #1 was told the physician was called and Bumex was ordered for the bleeding. The family member stated he did not understand why Bumex was ordered for the bleeding. The family member stated Resident #1 was on the blood thinner Eliquis and he was concerned about all the blood he saw on the sheets. The family member stated he told Resident #1 to request to go to the emergency room. An interview was conducted with the on-call physician, Nurse Practitioner (NP) #1, on 11/14/2024 at 5:10 PM. NP #1 explained that she worked as an on-call provider for the facility every eight to ten weeks on a rotational basis and did not know or visit the residents in the facility. NP #1 stated she vaguely recalled the phone call she received on the evening of 10/22/2024 regarding Resident #1. NP #1 stated that if she ordered for a one-time dose of Bumex to be administered it was likely she was told Resident #1 had edema in her leg. NP #1 stated if she had been told Resident #1 was on a blood thinner, had recent [NAME] surgery, and had bled through the bandage, she would have requested Resident #1 be sent to the emergency room for evaluation. NP #1 stated she relied on the nursing staff to provide her with the relevant information so she can ask relevant questions and give relevant orders. Documentation on an Emergency Medical Services (EMS) patient care record dated 10/22/2024 revealed EMS was called to the facility at 9:43 PM because Resident #1 was hemorrhaging/bleeding. Vital signs taken by the EMS on 10/22/2024 at 10:06 PM revealed Resident #1 had a blood pressure of 148/76, Pulse 86, Respiratory rate 19 and saturation of peripheral oxygen 97. The narrative on the EMS record stated, Upon arrival [Resident #1] was found lying supine in her bed with a sheet over her that was covered in blood. [Resident #1] was alert and oriented and not in any distress. RN came in and stated that [Resident#1] had been bleeding for about 45 minutes and could not control the bleeding. [Resident #1] stated she has skin cancer and had surgery done on her left leg, on Saturday [Resident #1's] dressing got changed and again on Tuesday only this time when the bandage was removed it caused [Resident #1] a lot of pain and she stated it felt like they ripped her skin off and that's when it began to bleed uncontrollably. [Resident #1] is on a blood thinner. RN packed the wound and applied pressure prior to our arrival but the wound kept bleeding. RN wrapped the wound up thinking it would stop bleeding, and it did not. Blood was seeping through bandages and sheets. Pt was moved over to stretcher via sheet method and taken out to unit where vitals were taken, and radio report was given. It was noted the condition at the emergency room destination was worse. Documentation in a discharge summary for Resident #1's emergency room visit on 10/22/2024, hospitalization, and discharge on [DATE] revealed the following information. Resident #1 was seen in the emergency room for postoperative bleeding of a 4 X 4 biopsy site on the left lower extremity. The medical decision-making portion of the emergency room notes stated, Patient has a large skin biopsy site to the left anterior shin that does have a clot and is only mildly oozing over the superior aspect. There is no good place to place a stitch as I do not want to pull off the whole clot and make the whole wound start bleeding. I placed combat gauze, and a pressure dressing and bleeding has been controlled. emergency room laboratory values revealed Resident #1 had anemia with a hemoglobin level of 7.3 g/dL (grams per deciliter) at 12:14 PM on 10/23/24 that dropped from 9.9 g/dl taken at 10:56 PM on 10/22/24. The normal range for a hemoglobin is 12.0 to 15.5 g/dL. Resident #1 had a near syncopal episode in the emergency room with the dropping of her blood pressure from 110 systolic to 90, oxygen saturation, and hemoglobin as the emergency room attempted suture ligation of the bleeding. Resident #1 received a blood transfusion of one unit of packed red blood cells and was hydrated aggressively with intravenous fluids. Resident #1 was admitted to the hospital for monitoring and a surgery consultation was ordered in case of continued bleeding. An interview was conducted simultaneously with the DON and the facility Administrator on 11/14/2024. The DON and Administrator agreed Nurse #4 should not have entered the room of Resident #1 unless there was an emergency, as the requests of the residents should always be honored. The DON confirmed there was no documentation of vital signs taken prior to the arrival of EMS for Resident #1. The DON indicated Resident #1 could have been sent to the emergency room immediately. An interview was conducted with the physician (MD #1) for Resident #1 on 11/18/2024 at 2:49 PM. MD #1 revealed the physician who performed the [NAME] surgery on Resident #1 did not request for the Eliquis to be stopped prior to the surgery nor after the surgery. MD #1 stated the wound was very superficial and the nurses who cared for Resident #1 on 10/22/2024 should be commended for attempting to stop the bleeding and sending her to the hospital when they identified the bleeding was not stopping. MD #1 stated Nurse #3 should have given the Eliquis, and he would not have told her to hold the Eliquis on 10/22/2024. MD #1 revealed he agreed with the order for Bumex because Resident #1 had a history of edema. MD #1 also revealed the best treatment for a low hemoglobin was a transfusion and he agreed with all the interventions provided by the hospital. MD #1 summarized his thoughts by saying he felt the facility had done everything appropriately for Resident #1 on 10/22/2024. B. Documentation on a physician's order dated as initiated on 10/19/2024 for Resident #1 revealed the left lower leg was to be cleaned with 1/2 tap water and 1/2 peroxide, Vaseline (or prescribed antibiotic ointment) applied, covered with a non-stick gauze pad (Telfa), and micropore paper tape. The wound care was to be completed daily every evening shift. Documentation on the October treatment administration record (TAR) for Resident #1 revealed the dermatology order for wound care after the [NAME] surgery was initiated on 10/19/2024 and was completed by Nurse # 6 on 10/19/2024 and 10/20/2024. Nurse #6 was interviewed on 11/14/2024 at 5:00 PM. Nurse #6 stated when she completed wound care for Resident #1 on 10/19/2024 and 10/20/2024 she had all the supplies she needed except for hydrogen peroxide. Nurse #6 revealed she did look in the nursing supply room but was unable to locate any hydrogen peroxide in the building that weekend. Nurse #6 stated she used standard nursing practice and cleaned the wound with normal saline instead of using ½ tap water and ½ hydrogen peroxide. Nurse #6 indicated she was very familiar with performing wound care and the wound had pink granulation tissue with only slight bleeding. An interview was conducted with the Director of Nursing on 11/14/2024 at 12:08 PM. The Director of Nursing confirmed that Nurse #6 was unable to locate the hydrogen peroxide in the facility as it was not a product usually used in wound care in the facility. The Director of Nursing indicated the facility did have hydrogen peroxide, but Nurse #6 was not able to locate it that weekend. The Director of Nursing stated that Nurse #6 should have called the physician to let them know the hydrogen peroxide was not available and obtain alternate orders for wound care. An interview was conducted with the physician (MD #1) for Resident #1 on 11/18/2024 at 2:49 PM. MD #1 stated that there was no difference in using normal saline versus using ½ tap water and ½ hydrogen peroxide to clean the wound other that it might have been easier to take off the bandage if hydrogen peroxide and tap water was used.