**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, review of hospital records, review of an ambulance run report, facility policy review, interviews with staff, and family, the facility failed to adequately monitor and provide necessary and timely services to prevent post-operative complications for Resident #81 who was admitted for care status post closed reduction (setting a broken bone without cutting the skin) external fixation (pins and other devices sticking out of the ankle hold together the broken pieces of bones within the ankle while the bones heal) of a right tibial [NAME] fracture (a type of break that occurs at the bottom of the tibia (shinbone) and involves the weight-bearing surface of the ankle joint). This resulted in Immediate Jeopardy and the potential for serious life-threatening harm on 04/16/23 when Resident #81, who received the anticoagulant medication Eliquis and antiplatelet medication Plavix concurrently despite an identified, severe drug interaction (increased risk of bleeding) between the two medications that was not addressed with the prescriber or pharmacy, was provided post-surgical wound care on 04/17/23 and 04/18/23 without orders from the surgeon, potentially compromising the integrity of the surgical site. The resident was subsequently transferred to the emergency room on [DATE] due to uncontrolled, excessive bleeding from the (surgical) pin sites, hypotension with a blood pressure of 94/47 with symptoms including feeling lightheaded and having cold and clammy skin. The resident required multiple blood transfusions and did not return to the facility upon discharge from the hospital. This affected one resident (#81) of three residents reviewed for wounds. The facility census was 80. On 05/03/23 at 5:03 P.M., the Director of Nursing (DON) and Administrator were notified Immediate Jeopardy began on 04/16/23, when the facility failed to timely identify a change in the resident's condition, failed to ensure timely communication with the surgeon and notification of wound concerns, and failed to timely monitor and identify potential medication interactions resulting in excessive bleeding and abnormal laboratory results requiring hospital intervention. The Immediate Jeopardy was removed on 05/04/23 when the facility implemented the following corrective actions: • On 04/19/23 at 2:00 A.M. Resident #81's surgical wound was noted to be bleeding excessively. The resident's nurse, Registered Nurse (RN) #183, contacted the nurse practitioner, (NP) #504, and Resident #81 was sent to the emergency room for evaluation. • On 05/03/23, at 5:30 P.M. the DON reviewed the medical records for 45 residents, Resident #1, #2, #5, #9, #10, #11, #15, #16, #20, #21, #24, #29, #33, #35, #36, #38, #39, #40, #41, #43, #44, #45, #47, #48, #49, #51, #53, #57, #59, #60, #62, #64, #65, #66, #72, #73, #74, #76, #77, #78, #79, #80, #83, #84, and #85 who were ordered blood thinning medications, including Plavix and/or Eliquis, to ensure that care plans were in place for blood thinners and any possible drug interactions were clarified with the physician. None were noted. • On 05/03/23 at 5:10 P.M., the Administrator, DON, and Medical Director had an Ad Hoc Quality Assurance Performance Improvement meeting to discuss the Immediate Jeopardy (IJ) form and the action plan. The Administrator spoke with Pharmacist #508 separately to discuss the IJ form and potential medication interactions. • On 05/03/23, at approximately 6:30 P.M. the DON reviewed the medical records for all 81 residents in the facility, over a seven-day lookback period, for evidence of unreported change in condition requiring physician intervention and none were noted. • On 05/04/23, at approximately 8:00 A.M. the DON drafted and began educating all licensed nursing staff via one or more of the following formats: text, email, phone calls, in-person, and Relias. The education included the topics: facility policy and procedure for monitoring change in condition and reporting the same to the physician; timely treatment for identified change in condition and procedure for identifying medication interactions and clarifying relevant medication orders with the physician when interactions are identified; and expectations for surgical wound care and need to notify physician and/or surgeon with any abnormal wound findings. As of 05/04/23, all seven Licensed Practical Nurses and 18 Registered Nurses were educated. Additionally, Wound Nurse Practitioner #502 and Nurse Practitioner #503 were educated. • On 05/04/23 at 2:55 P.M., the DON made a change to the Medication Administration Record (MAR) to have nurses document any changes in condition, abnormal wound findings, and any potential medication interactions before the end of their shift. • On 05/08/23, the DON and designees implemented a plan for random audits and monitoring of three residents daily/five days a week to ensure medication interactions were identified by the nurse and reported to the physician for clarification, as indicated; resident changes in condition are reported timely to the physician; and surgical wounds are being monitored appropriately and the physician is notified timely of any changes to the wound. These audits will be done until receipt of the 2567, at which time the facility will re-evaluate the audit scope and frequency. Staff responsible for completing the audits will be the DON, RN #164, #193, #224, LPN #213, STNA #107, and (Physical Therapy Assistant) PTA #178. Although the Immediate Jeopardy was removed on 05/04/23, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings Include: Review of Resident #81's closed electronic medical record revealed an admission date of 04/16/23 with diagnoses including closed reduction and external fixation of right tibial [NAME] fracture, iron deficiency anemia, hypertension, and ischemic cardiomyopathy (oxygen-rich blood is prevented from entering the heart and the heart muscle becomes enlarged, dilated, and weak). Review of Resident #81's hospital discharge orders (prior to his admission to the facility) dated 04/16/23 revealed to keep the external fixators (surgical wound site) clean and dry. (Apply) ice, elevate (the right lower extremity), and non-weight bearing to the right lower extremity. The hospital discharge orders indicated to call the doctor if you have persistent or heavy bleeding, redness, swelling, or pus or drainage from the wound. (Surgeon #503 was listed as the primary physician for Resident #81's case). The hospital discharge orders also noted to continue Eliquis (anticoagulant medication) five milligrams (mg) twice daily (the resident was taking this medication prior to his hospitalization) and Plavix (antiplatelet medication) 75 mg daily. Review of Resident #81's facility admission orders, dated 04/16/23, revealed no evidence of a treatment/dressing change order to the external fixator (surgical) site of the right tibial [NAME] fracture. The resident's admission medication orders included Eliquis 5 mg twice daily in the A.M. and P.M. and Plavix 75 mg daily in the A.M. As part of the facility ' s admission protocol, the resident was ordered to have a complete blood count (CBC), basic metabolic panel (BMP) and Vitamin D level obtained on 04/17/23. Review of Resident #81's order note, dated 04/16/23 at 2:10 P.M. and authored by Registered Nurse (RN) #226, revealed there was a severe drug to drug interaction of increased bleeding when Plavix and Eliquis are administered together. Further review of the progress notes revealed no evidence the drug-to-drug interactions were reported to the resident ' s primary care provider, surgeon and/or discussed with pharmacy. No changes or new orders were noted following the order note. In addition, there was no evidence the facility implemented a plan to timely identify or monitor for increased bleeding. Review of Resident #81's admission note, dated 04/16/23 at 3:00 P.M. and authored by RN #212, revealed the resident had a surgical dressing intact and external fixator in place to the right lower leg. Old drainage was noted around the pins. This was the only information provided regarding the surgical wound in this progress note. Review of Resident #81's admission skin assessment (part of the electronic health record) and paper admission skin assessment, dated 04/16/23 and authored by RN #212, revealed the resident had a right leg fixator and dressing intact with old drainage noted around pins. There was no other documentation or description of the area noted. Review of Resident #81's nurse's note, dated 04/16/23 at 7:54 P.M. and authored by RN #212, revealed the Certified Nurse Practitioner (CNP) (name not provided) was updated of the resident's admission and medication were reviewed. There were no additional notes related to a possible drug interaction or increased bleeding from the concurrent administration of Eliquis and Plavix noted at this time. Review of Resident #81's brief interview for mental status (BIMS) evaluation dated 04/17/23 revealed the resident's BIMS score was 15 (out of 15), reflecting the resident's cognition was intact. Review of Resident #81's laboratory results, dated 04/17/23, revealed the resident's laboratory testing, CBC, BMP, and Vitamin D levels were collected at 8:48 A.M. on 04/17/23 and the results were faxed to the facility on [DATE] at 4:20 P.M. The resident hemoglobin results were 8.5 grams per deciliter (g/dL) (normal range of 14-18 g/dL). On 04/17/23 at 1:38 P.M. a progress note, entered by Licensed Practical Nurse (LPN) #120, revealed the LPN documented she called the surgeon's office to report bleeding from the pin site on the right ankle. The LPN entered another skilled note, dated 04/17/23 at 2:10 P.M. which indicated the resident had developed a new area of edema to the right toes. There was no evidence an assessment was completed of the areas or surgical wound at this time. Review of Resident #81's progress note, dated 04/17/23 at 3:35 P.M. and authored by RN #140, revealed the resident's (surgical) dressing was changed due to wet dressing to heel, serosanguineous (clear yellowish fluid with some blood). Resident tolerated dressing change well. No redness to pin site or odor observed. The yellow pin site lateral has a small amount of dried blood. The leg was iced and elevated on a pillow. There was a 0.3 (centimeter) by 0.3 (centimeter) scabbed area noted on the bottom of the heel. Resident reported the area was old. Review of Resident #81's progress note, dated 04/17/23 at 4:23 P.M. and authored by RN #140, revealed the resident would follow up with the physician to monitor pin sites on Thursday (04/20/23). Updated on dressing change due to the dressing was saturated at the heel. There was no documentation of who was updated on the dressing change or a description of what saturated the dressing. Review of Resident #81's paper shower sheet, dated 04/17/23 and completed by State Tested Nursing Assistant (STNA) #219 (no time indicated), revealed Resident #81's right lower extremity was wrapped in kerlix, heel saturated. Notified nurse of dressing. There was no documentation describing what saturated the dressing. Review of Resident #81's telephone orders revealed on 04/17/23 RN #140 wrote a telephone order from Surgeon #501, which was not signed by Surgeon #501 or any of the resident's healthcare providers, okay for dressing change to right lower extremity (RLE) done by this nurse. No further orders. Okay to continue antibiotic and surgeon to monitor pin sites at follow up appointment. Review of Resident #81's progress note, dated 04/17/23 and authored by Nurse Practitioner (NP) #504, revealed nursing (not identified) reported there was some bleeding noted to the resident's surgical dressing after he (the resident) reported he bumped it (the right lower extremity) on the bed throughout the night several times and an episode when staff had rolled him., (No clarifying information was provided regarding the episode). Blood was noted to the dressing on the right lower extremity. The plan was to follow up with surgical team to check the bleeding as well as perhaps need an x-ray to assess continued stability of this moving forward. The note indicated the resident was on Eliquis for deep vein thrombosis prophylaxis at this point of time. No changes were made to the resident's medication regimen at that time. In addition, there was no evidence the surgical site was assessed by the CNP or the resident's surgeon was consulted. Review of Resident #81's progress note, dated 04/18/23 at 12:46 A.M. and authored by RN #180, revealed dressings were clean, dry, and intact. There was no description or location of the dressings. Review of Resident #81's skin note, dated 04/18/23 at 11:23 A.M. and authored by LPN #213, revealed the resident was seen by the wound team today. External fixator to the right lower extremity was present on admission. The skin note indicated to cleanse each pin site with Dakin's (a solution of sodium hypochlorite (diluted bleach) and other stabilizing ingredients, traditionally used as an antiseptic to prevent infection) quarter strength using a different Q-tip for each pin. Apply Xeroform (a yellow non-adherent dressing for wounds without much drainage that promotes a moist wound environment) around each site, cover with dry dressing and wrap with Kerlix (gauze) daily and as needed. Review of a handwritten verbal order, dated 04/18/23, authored by LPN #213 and given by Wound NP #502, revealed to cleanse the right lower extremity pin sites with Dakin's 0.25% solution, use a different Q-tip to cleanse each pin site. Apply Xerofoam around the pin sites cover with dry dressing and wrap with Kerlix daily and as needed. Review of Resident #81's paper wound note, dated 04/18/23 and authored by Wound NP #502 revealed the resident had a right lower extremity external fixator that was present on admission. There were seven pin sites, small bloody, no erythema (redness). Previous treatment Dakin's half (½) strength to pin sites daily. New orders were cleansing each pin site with Dakin's 0.5% solution, use different Q-tip to cleanse each site, apply Xeroform around pin sites, cover with dry dressing, wrap with kerlix, change daily and as needed. Review of Resident #81's treatment administration records (TAR), dated 04/2023, revealed an order was written on 04/18/23 to use Dakin's half strength solution to external fixation- apply sufficient amount externally every day to ulcer. The treatment was administered on 04/18/23, then the order was clarified on 04/18/23 to cleansing each pin site with Dakin's 0.5% solution, use different q-tip to cleanse each site, apply Xeroform around pin sites, cover with dry dressing, wrap with kerlix, change daily and as needed. Review of Resident #81's skilled note, dated 04/18/23 at 12:35 P.M. and authored by LPN #510, revealed the resident's right toes were edematous and surgical wound to right lower leg needed reviewed. Review of Resident #81's progress note, dated 04/18/23 and authored by NP #504, revealed the resident reported yesterday an episode where he had been rolled over by nursing staff during changes and he had bumped his leg which resulted in bleeding. The note indicated the surgeon's office was notified of bleeding from the pin sites with no new orders as the patient would be seen in the office on Thursday (04/20/23). Patient on Eliquis with no abnormal bruises. The right lower extremity was wrapped with gauze, dried blood noted on gauze, however wound team canged the dressing, and some bleeding was seen. The resident's hemoglobin was 8.5. Continue to monitor closely. There was no documentation of who notified or when the surgeon's office was notified. Review of Resident #81's progress note, dated 04/19/23 at 2:05 A.M. and authored by RN #183, revealed the resident was sent to the emergency room due to excessive bleeding from the pin sites. The resident was hypotensive with a blood pressure of 94/47, pulse 68. Resident #81 was assessed to be lightheaded, cold, and clammy. The (unidentified) on call CNP was updated with orders to send to the emergency department for evaluation. Review of the Ambulance Run Report, dated 04/19/23, revealed the ambulance company was called on 04/19/23 at 1:52 A.M. and arrived at 1:52 A.M. The report contained the following information: Upon arrival a [AGE] year-old man was found in semi-Fowlers position (on his back with the head of the bed elevated 30-45 degrees). The resident presented with bleeding. Initial impression post-operative procedure complication. The male was bleeding from post operation surgery site that was cleaned at approximately 9:00 A.M. and had been bleeding slowly and steadily (since that time). The nursing home changed the dressing twice and it was full of blood prior to Emergency Medical Service (EMS) arrival. EMS were informed the resident had surgery four days prior. The bleeding was not completely controlled, there was clotting of blood on outside of dressing. Placed two abdominal pad bandages (larger and thicker than gauze and used for heavily draining wounds) to medial side of lower leg. Local hospital advised to take patient to general hospital due to surgery was performed there. Bleeding had slowed down but not controlled during transport. Arrived at the emergency room at 3:13 A.M. Review of a physician communication note entered on 04/19/23 at 4:49 A.M., (after the resident had been discharged ) as a late entry for 04/18/23 at 6:42 P.M. and authored by the DON, revealed Resident #81's was bleeding from pin sites of his fixator. The lower right foot. New dressing applied and resident was currently on blood thinner. Nurse Practitioner #504 ordered to reinforce the dressing and ordered a complete blood count (CBC) and basic metabolic profile (BMP) in the morning (04/19/23). Review of Resident #81's transfer to hospital summary note, dated 04/19/23 at 10:39 A.M. and authored by RN #228, revealed the resident was admitted to the hospital with post operative hemoglobin drop. Review of Resident #81's hospital emergency room notes, dated 04/19/23 revealed Resident #81's chief complaint was bleeding. The resident was on Eliquis and Plavix and presented with acute blood loss. His hemoglobin was 7.1 then 5.9 (normal 14-18 for males) on 04/19/23 and two units of packed red blood cells (PRBC) were ordered. The resident was hypotensive in the 90's (systolic blood pressure) but after receiving blood products, intravenous fluids (IVF), and controlled bleeding, his blood pressure (BP) stabilized. The resident stated his leg started bleeding at the facility yesterday morning and the staff were changing the dressings. He woke up overnight in a pool of blood and came to the emergency room. The resident leg was bleeding heavily, saturating chux pads (large, disposable waterproof pads generally used for urinary incontinence) underneath as well as his bandages and (the blood) dripped to floor. Dressings and soaked chux pad taken off and pad replaced. The source of bleeding was found, and pressure applied Orthopedics notified and would be down to assess. The resident was admitted to the hospital for further evaluation and treatment for right lower extremity bleeding from recent surgical site, acute blood loss anemia, hypotension, and leukocytosis (high white blood cell count). On 04/28/23 at 12:00 P.M. an interview with Medical Secretary (MS) #503 from Surgeon #501's office revealed the surgeon's orders were usually to keep the (surgical) dressing dry, clean, and intact until the first appointment. MS #503 reported she had no documented evidence the facility had called on 04/17/23 or 04/18/23 regarding Resident #81. MS #503 reported she would have documented a call if it was received. On 04/28/23 at 2:00 P.M., interview with Registered Nurse (RN) #140 revealed she spoke to the surgeon's nurse via phone on 04/17/23 and relayed that she had changed the resident's dressing earlier as it had been saturated down to the heel. The surgeon's nurse did not give any new dressing orders. RN #140 revealed she had replaced the dressing with the same dressing she had taken off (Petroleum gauze, abdominal pad, and wrapped with Kerlix). RN #140 verified she did not have an order for the dressing changes and did not document the supplies she used to change the dressing. RN #140 revealed the yellow (surgical) pin had old blood noted on it. In addition, there was a scabbed area on the right heel that was not observed on admission because it had been covered with a dressing. When asked to clarify what saturated down to the heel meant and what was saturating the dressing, RN #140 indicated she was unable to recall due to her lack of documentation and the time that had elapsed since the date in question. On 04/28/23 at 11:09 A.M., interview with Licensed Practical Nurse (LPN) #213, who rounded with the Wound NP #502 on 04/18/23 revealed she believed Wound Nurse Practitioner (WNP) #502 must have thought the resident was previously receiving Dakin's solution wound care to the surgical incision and continued the order adding to use a different Q-tip with each pin site. LPN #213 verified the Dakin's order was to be to the right heel and not the resident's surgical site. On 05/02/23 at 11:05 A.M., interview with the Director of Nursing (DON) verified there were no orders from the surgeon for routine care of the surgical wound to the right lower extremity until 04/18/23, after RN #140 had already provided wound care to the resident. On 05/02/23 at 11:23 A.M., during a telephone interview with Resident #81's wife, the wife voiced concerns regarding the care provided by the facility to her husband. The wife stated the facility had no business removing the surgical dressing. The wife stated the dressing was to remain intact until the resident followed-up with the surgeon on 04/20/23. Resident #81's wife indicated on 04/17/23 the dressing was changed, and the dressing was not saturated with blood. On 04/18/23 a staff member (not identified by Resident #81's wife) used a Q-tip with peroxide and removed the scabbed areas to the surgical site as reported to her by Resident #81. The surgical area then started bleeding and did not stop all day. The resident's wife stated she had reported her concerns to staff (not named by Resident #81's wife) regarding the resident's continued bleeding, but the staff kept telling her the bleeding was due to the resident being on blood thinners. Further interview revealed the resident's wife had the DON come in and look at the resident's leg and the DON acted like it didn't phase her and said it was because the resident was on blood thinners. On 05/02/23 at 12:02 P.M. interview with the DON revealed, despite not having orders to provide care at the surgical site and not contacting the surgeon for treatment orders, she believed the nurse was acting within her scope of practice and changed the dressing as part of her assessment. The DON also verified there was no documentation of the treatment RN #140 performed to the surgical sites on 04/17/23. The DON confirmed Resident #81's dressing was changed prior to notification of the surgeon on 04/17/23. On 05/02/23 at 1:00 P.M., an interview with State Tested Nursing Assistant (STNA) #219 revealed she had completed Resident #81's bed bath and shower sheet on 04/17/23. STNA #219 clarified the dressing to the right lower extremity was saturated with blood. A follow-up telephone interview with STNA #219 was attempted on 05/08/23 but no return call was provided. On 05/02/23 at 1:42 P.M. interview with the DON confirmed Resident #81's laboratory results with the low hemoglobin level of 8.5 was received on 04/17/23, NP #504 saw the laboratory results on 04/18/23 and signed the lab report indicating the results were reviewed. There was no evidence of any new orders at that time. On 05/02/23 at 3:10 P.M., interview with RN #140 revealed she doesn't know what time she notified the provider of Resident #81's lab results from 04/17/23 because she did not document a time or specifically who she notified. RN #140 revealed the nurses usually wait until the end of the day and review all abnormal labs with the provider and then the provider would sign the laboratory results the next day. RN #140 confirmed there was no documented evidence of when and what results were discussed with the provider or if any new orders were received. On 05/02/23 at 4:23 P.M. a telephone interview with Surgeon #501 confirmed there was no evidence (nothing noted on the call logs in his office or through the call logs with his answering service, no record of calls or texts to his cell phone) the facility had contacted him on 04/17/23 or 04/18/23 with the Resident #81's condition change or that he was bleeding and had a low hemoglobin level. The surgeon reported he was unsure how it got past medical at the hospital that the resident was taking both Plavix and Eliquis (as they increased the resident's risk of bleeding and complications). Further interview revealed with the resident having a hemoglobin level of 8.5 with fresh bleeding, that would warrant a blood transfusion. The surgeon also verified he did not, and he would not have given orders to cleanse the pin sites because cleaning the pin sites could be a contributing factor in the resident's bleeding. The surgeon stated his orders were always to keep the dressing intact until the resident's surgical follow-up as the surgical areas need additional pressure to clot properly. On 05/03/23 at 12:19 P.M., telephone interview with Pharmacist #508 revealed every facility electronic medical record was set up differently, however the facility would enter the admission orders and (medication) interactions, she believed, would pop up on the notes. On 05/03/23 at 3:11 P.M. telephone interview with NP #504 and Wound NP #502 concurrently revealed the wound nurse had reported the Dakin's order was already in place for Resident #81 on 04/18/23 and the new order change following this order was just to use a different Q-tip with each site. Neither NP indicated they were sure where the original order came from to use Dakin's and neither acknowledged being able to access the electronic medical record to review the information. NP #504 reported he did not have access to the electronic medical record (he relied on the nurse with him when he does rounds), he stated he would be notified of drug interactions by facility/pharmacy, and he reviewed resident medications on admission. NP #504 confirmed he was aware of the resident's surgical complication and ordered a CBC and BMP to be collected on 04/19/23 and not immediately. On 05/04/23 at 12:53 P.M., interview with LPN #213 revealed the order provided by Wound NP #502 on 04/18/23 to cleanse the external fixator with Dakin's solution, was incorrectly entered and the Dakin's order was not to be applied to the external fixator and was ordered to be applied to a pressure ulcer on the left heel. A follow-up interview on 05/08/23 at 1:20 P.M. with LPN #213, who rounded with the Wound NP #502 on 04/18/23 and was present during the wound care provided to Resident #81, revealed Wound NP #502 performed the treatment to Resident #81's surgical incision. There was a golf ball size of dark moist blood noted on the old dressing. The pins had scabs and dried blood around them. LPN #213 reported Wound NP #502 had used Dakin's and Q-tips to cleanse the pins and at least one scab did come off during the treatment administration. Review of the facility undated policy titled Wound Care revealed the facility would strive to provide the most appropriate and individualized treatment of wounds. The nurse would perform a skin assessment during the initial admission assessment. Wounds shall be assessed and documented on with dressing changes. Wound documentation shall include, but was not limited to: etiology, description, and staging of the wound; measurements of the wound, including length, width, and depth (including tunneling measurements); wound bed description, granulation, type and description of drainage and odor. Review of the facility policy Change in Resident's Condition or Status dated 06/2006 and revised 05/15/20 revealed the facility shall promptly notify the resident, his/her attending physician, and responsible party of changes in the resident's condition or status. Nursing services shall notify the resident's physician when: there was a significant change in the resident's physical, mental or psychological status; there was a need to alter the resident's treatment significantly; deemed necessary or appropriate in the best interest of the resident. In the event of a medical emergency or a rapid deterioration in the resident's condition, family and physician notification would be made immediately. The deficiency represents non-compliance investigated under Complaint Number OH00142280.