**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility contracts, facility policy, medical record review, facility documentation and interviews, the facility failed to ensure 1 of 6 residents (Resident #5) reviewed for anticoagulation therapy, received anticoagulation therapy for the diagnoses of Atrial Fibrillation (A-Fib) and prevention of blood clot formation. Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified related to the facility's failure to ensure the physician reviewed the total program of care, including medications, which resulted in Resident #5 not receiving anticoagulation therapy from 10/31/2023-12/5/2023. The Executive Director (ED) was notified of the Immediate Jeopardy (IJ) on 2/28/2024 at 4:20 PM, in the conference room. The facility was cited Immediate Jeopardy at F-684. The facility was cited Immediate Jeopardy at F-684 at a scope and severity of J which constitutes Substandard Quality of Care. The IJ was effective on 11/15/2023 and was removed on 12/5/2023. The facility's corrective actions were taken on 12/5/2023. The Immediate Jeopardy was cited as past non-compliance for F-684 and the facility is not required to submit a Plan of Correction. The IJ was effective on 11/15/2023. The IJ was removed on 12/5/2023. The facility's corrective action plan, which removed the immediacy of the jeopardy, was reviewed and corrective actions were validated onsite by the surveyor on 2/29/2024. The findings include: Review of a facility contract titled, PHARMACY CONSULTANT AGREEMENT, showed .as of July 1, 2017 .RESPONSIBILITIES OF PHARMACY .Consultant shall identify any irregularities as defined in the State Operations Manual .Consultant will provide a summary report .which (a) documents that no irregularity as identified, or (b) reports any irregularities . Review of a facility contract titled, Performance Requirement & Practice Agreement, revised 1/3/2019, showed .NP [Nurse Practitioner #2] .Visits may alternate with a .NP .The physician may delegate to alternate the routine monthly visit or acute care visit to his/her nurse practitioner .Documentation in the patient's medical record will be comprehensive and will indicate a thorough examination and evaluation of the patient each visit . Review showed this contract was signed by NP #2 on 9/25/2019. Review of a facility contract titled, Performance Requirement & Practice Agreement, revised 9/1/2022, showed .NP #1 .Visits may alternate with a .NP .The physician may delegate to alternate the routine monthly visit or acute care visit to his/her nurse practitioner .Documentation in the patient's medical record will be comprehensive and will indicate a thorough examination and evaluation of the patient each visit . Review showed this contract was signed by NP #1 on 12/13/2022. Review of a facility contract titled, Performance Requirement & Practice Agreement, revised 9/1/2022, showed .MD [Medical Director] .The physician must visit and complete an initial comprehensive assessment .after admission .Documentation in the patient's medical record will be comprehensive and will indicate a thorough examination and evaluation of the patient each visit . Review showed this contract was signed by the MD on 1/18/2023. Review of a facility policy titled, Physician Services Guidelines, revised 3/10/2023, showed Documentation in the medical record must reflect supervision of the medical care of each patient in the facility .At the time of each visit, the physician must review the patient's total program of care, medications, treatments, and care plan . Review of a facility policy titled, Pharmacy Services and Medication Regimen Review, reviewed 8/28/2023, showed .The facility maintains the resident's highest practicable level of physical .well-being and .minimizes adverse consequences related to medication therapy to the extent possible, by providing oversight by a licensed pharmacist .The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing . Review of the medical record showed Resident #5 was admitted to the facility on [DATE], post hospitalization with diagnoses including Atrial Fibrillation, Long Term (Current) Use of Anticoagulants and Myocardial Infarction. Review of the hospital DISCHARGE SUMMARY for Resident #5 showed .discharge date : [DATE] .[on] 10/28/23 .INR [international normalized ratio] 1.6 .Discharge Medications .START taking these medications .apixaban [anticoagulant] 5 MG [milligram] .Commonly Known as Eliquis .1 tablet .2 .times a day .STOP taking these medications rivaroxaban [anticoagulant] 15 MG .Commonly known as Xarelto . Review of the hospital Discharge to Outside Facility Form for Resident #5 showed .10/31/23 Discharge Patient .Meds [medications] to Resume Upon Discharge .rivaroxaban 15 MG .2 .times a day with breakfast and dinner . Review of the admission Minimum Data Set (MDS) assessment, dated 11/2/2023, showed Resident #5's Brief Interview of Mental Status (BIMS) score was 3, indicating the resident had severe cognitive impairment and required assistance of one person with activities of daily living (ADL's). Review of the discharge MDS showed Resident #5 was discharged on 12/17/2023, to the hospital and did not return. Review of the facility progress notes for Resident #5 from 10/31/2023 through 12/5/2023, showed NP #1 saw the resident 12 times between 10/31/2023 and 11/30/2023, and documented .Reviewed meds . with each visit. Review of Resident #5's assessment by the MD on 11/9/2023, included a history and physical which showed .Patient also had A-fib sick sinus syndrome [group of heart rhythm problems] .Eliquis was continued for stroke prophylaxis [preventative] .Available hospital records reviewed today. Medications and plan of care reviewed .Reviewed and appropriate . Review of a pharmacy consultation report for Resident #5 dated 11/20/2023, showed .To: [MD]; [Director of Nursing (DON)] From: [Pharmacy Consultant] .Recommendation: Please discontinue Glipizide [antidiabetic] . Review showed no documentation of irregularities or mention of conflicting orders for anticoagulation were noted and the report was signed by the MD on 12/1/2023 and DON on 12/7/2023. Review of physician orders for Resident #5 showed Eliquis was ordered on 12/5/2023, 5 milligrams 2 times a day at 8:00 AM and 2:00 PM, for clot prevention. Documentation showed no orders for Xarelto, Eliquis, or any anticoagulant prior to 12/5/2023 . Review of the facility's MOBILE IMAGES report for Resident #5 showed .12/05/2023 .Ultrasound exam of head and neck .There is no evidence of mass or hematoma [pool of mostly clotted blood] involving the left occipital [back of the head] area .12/05/2023 .SKULL SERIES, 3 VIEWS .No intrinsic bony abnormality is identified .12/05/2023 .SPINE, CERVICAL 2-3 VIEWS .No fracture or other acute findings identified . Resident #5's NP #1's progress note, dated 12/5/2023, showed .History of Present Illness: Resident seen for acute reports of head pain .he was lying in bed, alert, no acute distress .Noted a small circular spongy area that seemed to be slightly discolored .No decrease in range of motion noted to neck .had concern for bleeding as resident is supposed to be on Eliquis twice daily. I performed a medication review to assess milligram [dose] and noted that resident's Eliquis was not on his MAR [medication administration record]. Given that resident had not had Eliquis since admission and given his symptoms with medical history it was best to send resident to ER [emergency room] for eval [evaluation] and treat . Review of the hospital ER records for Resident #5 showed .Date of Service 12/5/2023 4:15 PM .Chief Complaint .Neck Pain .No known injury .Patient cannot recall any trauma .Patient states that whenever he twists his neck to the left hurts the worst. No neurologic deficits noted .Neurological: Negative for weakness .He is not in acute distress .Patient likely with torticollis [condition in which the neck muscles contract]. Will discharge home with supportive treatment .CT [computed tomography] head .No CT evidence for acute intracranial abnormality .CT Cervical Spine .There is no acute fracture or dislocation . Review of a facility email document, dated 12/27/2023, concerning Resident #5 from the Medical Director to the Executive Director (Administrator) showed .On 10/31/2023 Patient [Resident #5] was discharged from the hospital and admitted to the nursing home .Upon arrival to the nursing home, all medications per discharge summary was continued. There was a question about anticoagulation, and the nurse discussed with the nurse practitioner caring for the patient about anticoagulation issues, per the nurse practitioner she gave directions to stop Xarelto and start Eliquis 5 mg [milligrams] bid [twice a day] However there was some confusion and the nurse felt that she received directions to stop Xarelto but was unsure if she had to resume Eliquis. Accordingly anticoagulation was not resumed from 10/31/2023 through 12/5/2023 when he went into the emergency room .CT scan on 12/5/23 showed no evidence of stroke or Bleeding/hemorrhagic changes in the brain at this point patient was discharged back to the nursing home and at this point anticoagulation with Eliquis was appropriately resumed on 12/5/2023 .It is certainly unfortunate that there was some miscommunication leading to anticoagulation not being resumed on 10/31/2023 . During an interview on 2/20/2024 at 11:00 AM, the DON stated .when he [Resident #5] came in on admission there was two different medicines which were 2 separate anticoagulants .the one that was in the admission packet was Xarelto and the one .brought [by EMS transporting Resident #5] which was the discharge summary orders .[for] Eliquis. So when the admitting nurse [License Practical Nurse (LPN ) #1] saw this she called the nurse practitioner [NP #1] .asked her about having 2 of them [anticoagulants ordered] and the nurse practitioner told her to discontinue the Xarelto but never told her to go ahead and initiate the Eliquis .the nurse practitioner assumed he would still be getting the Eliquis .the provider [NP #1] had done several medication reviews on him [Resident #5] and the pharmacy consultant did a medication review also and he didn't catch the discrepancy .On 12/5 [12/5/2023] he was complaining of neck pain and she [NP #1] realized he was not on Eliquis . During an interview on 2/21/2024 at 10:30 AM, NP #1 stated .he was supposed to be on Eliquis when he was admitted .I came over .looked at the papers with her [LPN #1] .I told her .start the Eliquis .[Resident #5] was complaining of neck pain at the back of his neck .when I discovered that it [Eliquis] had not been ordered .I sent him to the ER to do diagnostics .thorough work up .they [hospital] did a CT of his head and neck and there wasn't any findings of fractures, clots anything like that .sent back to the facility and he was started back on his Eliquis the same day that he went out to the ER and came back on the 5th [12/5/2023] .I did a PT/INR on him before he went to the ER .his INR was 1.7 and with someone with his medical history you would want it [the INR] to be between 2 and 4 . During a telephone interview on 2/21/2024 at 11:40 AM, LPN #1 stated .there is always that one set of admission orders that they fax over to admissions [nurse] and I had them before EMS arrived .the faxed orders are the ones that we put in the system [Point Click Care (PCC)] .all those orders were put in before he [Resident #5] got to the facility .the one [anticoagulant] that was on there was the Xarelto .when he arrived .the papers .brought with him said Xarelto and Eliquis .pharmacy called to see which one was .[to] be the one given. I told them I would call [NP #1] .she verbally told me over the phone to dc [discontinue] the Xarelto and she would reevaluate the next day .she did not go over the papers with me .she just said to dc the Xarelto and that was the last thing she said about it .I dc'd the Xarelto that she said to .the Eliquis wasn't on the faxed [admission] orders so it wasn't put in the system so when she said to dc the Xarelto he had no blood thinners [anticoagulant] at all ordered .I figured she would do what she said and reevaluate and she would put him on one [anticoagulant] the next day .once he started getting sick and he was sent out that's when they realized that he wasn't on any .he hadn't gotten any blood thinners from when he got there [10/31/2023] until he went out to the hospital [12/5/2023] . During a telephone interview on 2/23/2024 at 1:15 PM, the Pharmacy Consultant stated .as the Consultant I just do monthly reviews .with the orders that come across if an order doesn't get entered in PCC the pharmacist at the pharmacy would have no way of knowing that and I would not see it until the regular monthly review .main thing I'm looking at is if it's a new admission I will look at the admission orders .I would have looked at the orders what they are on currently what changes were made and why .I did not notice the discrepancy I did look at both documents .I look at the diagnoses too .yes, I look at the H&P [history and physical], new orders, and a discharge summary .I honestly don't know how it [anticoagulant] got missed . During a telephone interview on 2/23/2023 at 1:45 PM, the MD stated .that H and P [history and physical] review I dictated [on 11/9/2023] from the discharge summary from the hospital .I thought he was supposed to be stopped from the Xarelto and started on Eliquis and that was missed .I don't think I caught it .no I did not pick up on that .there could have been a thrombotic stroke that could have happened but it did not happen .it could be possible it could have happened from not being on the blood thinners for 4 to 5 weeks [Resident #5 did not receive anticoagulation therapy for the first 34 days of his stay] . During an interview on 2/26/2024 at 2:40 PM, the ED stated .the providers [physician (MD) and nurse practitioners] and the pharmacy consultant didn't catch that he [Resident #5] was not on an anticoagulant . The facility's corrective actions were validated onsite by the surveyor on 2/29/2024. The corrective action plan included a Root Cause Analysis (RCA) and was completed by the ED and DON on 12/5/2023. Review of the RCA form, dated 12/5/2023, showed .Problem: [Resident #5] admitted with orders for Xarelto, however Eliquis mentioned in dc [discharge] summary. Admitting nurse contacted NP [#1] for clarification and order given to d/c Xarelto. Resident [#5] seen by multiple providers on multiple occasions with medication reviews being done. On 12/5/23 resident was seen for neck pain and noted to not be on an ACO [anticoagulant]. At this point, concern noted about possible clot in head/neck area related to neck pain and resident not actively being on [Eliquis]. Provider [NP #1] assumed that nurse [LPN #1] would understand that Eliquis needed to be added to orders. Providers [NP's or MD] nor pharmacist caught this during medication review . Review of the RCA continued and showed 3 Why's were documented as follows: Why 1 Per providers, they do not review all medications. However, it is documented that all meds have been reviewed on several occasions. Per pharmacist, he conducted a thorough medication review and did not feel that this resident needed to be on an ACO per his review. Why 2 Providers and pharmacist failed to follow medication management, pharmacy services and medication regimen review, and physician services guideline policies. These policies were failed by failing to conduct a thorough medication review as outlined by these policies. Why 3 Root Cause Analysis Conclusion: Providers and pharmacist failed to follow facility policies which resulted in a failure to complete a thorough medication review. This resulted in this resident not being on an ACO. Review of Mobile Images report, dated 12/5/2023, for Resident #5 confirmed x-ray was performed at facility with no negative findings. Review of Mobile Images report, dated 12/5/2023, for Resident #5 confirmed Ultrasound was performed at facility with no negative findings. Review of facility Witness Interview/Statement Form dated 12/5/2023, confirmed the resident (#5)'s family was notified by the facility and the ER. Review of a Health Status Note dated 12/5/2023, for Resident #5 confirmed .PT/INR at this time PT 14.9 INR 1.2 . Review of NP #1's progress note, dated 12/5/2023, for Resident #5 confirmed the resident was seen by provider. Review of the ER records for Resident #5, dated 12/5/2023, showed No CT evidence for acute intracranial abnormality and the resident was diagnosed with Torticollis. Resident #5 was sent back to facility the same day. Review of the RCA continued and showed, 2.) How will the facility identify other residents who have the potential to be affected by the same deficient practice? 2a.) Review of 100% of all residents on ACO-no issues identified. Person responsible Licensed Nurse Evaluation method Audit. Goal or Measure of Success and Date 12/5/2023 Evaluation Date/Results Bring findings to QAPI [Quality Assurance and Performance Improvement] Meeting. Review of ACO Audit 2A showed a list of 22 residents on ACO with ACO orders and resident care plans. The audit was completed on 12/5/2023 by the DON with no issues identified. Interview on 2/28/2023 at 3:00 PM, with the DON, confirmed 100% of residents on anticoagulation medication were reviewed on 12/5/2023 with no negative findings. 2b.) Review of ACO Meeting-no issues identified. Person responsible Licensed Nurse Evaluation method Audit Goal or Measure of Success and Date 12/5/202 Evaluation Date/Results Bring findings to QAPI Meeting. Review of the ACO Audit 2B showed ACO Meeting to ensure proper order for 100% of residents on ACO with 22 residents listed. Interview with the ED on 2/28/2023 at 3:15 PM, confirmed 100% of residents on ACO were brought to the impromptu QAPI meeting on 12/5/2023. 3.) What systemic change will be made to ensure the deficient process does not reoccur? On 12/5/2023 Provided education to Medical Director (MD)/Nurse Practitioners (providers) on Medication Reconciliation across the Continuum of Care policy. Physician Services Guidelines policy, Medication Management policy, ACO PIP [Performance Improvement Plan] and processes, entering orders expectation, medication review expectation, and Anticoagulation Management/Coumadin Therapy policy. Review of the facility's Education Acknowledgment form for the MD, NP #1, NP #2, and facility in-service sign in sheets showed the above education was completed on 12/5/2023. Telephone interview with NP #1 on 2/23/2023 12:30 PM, confirmed she was educated on the Medication Reconciliation across the Continuum of Care policy, Physician Services Guidelines policy, Medication Management policy, ACO PIP and was aware of the processes. Telephone interview with the MD on 2/23/2023 at 1:45 PM, confirmed she was educated on the Medication Reconciliation across the Continuum of Care policy, Physician Services Guidelines policy, Medication Management policy, ACO PIP [Performance Improvement Plan] and processes. Telephone interview with NP #2 on 2/23/2023 3:40 PM, confirmed she was educated on the Medication Reconciliation across the Continuum of Care policy, Physician Services Guidelines policy, Medication Management policy, ACO PIP and processes. Review of the facility's corrective actions showed on 12/5/2023, education was provided to the Pharmacist on Pharmacy Services and Medication Regimen Review policy, Medication Reconciliation Across the Continuum of Care policy, ACO PIP plan and processes, and medication review expectations. Review of facility's Education Acknowledgment Form for the Pharmacy Consultant showed the above education was completed on 12/5/2023. Telephone interview on 2/23/2024 at 2:30 PM, with the Pharmacy Consultant confirmed he was educated as the facility documentation review showed and was aware of the processes. Review of facility documents showed on 12/5/2023, education was provided to all licensed nurses on Medication Reconciliation Across the Continuum of Care policy, Administration of Medications policy, Anticoagulant Management/Coumadin Therapy policy, ACO PIP plan and processes, and assistance available for any questions or concerns of discrepancy regarding medication. Review of the facility's in-service sign in sheets and employee list of licensed nursing staff showed the above training was completed on 12/5/2023. Interviews of licensed nursing staff were conducted on 2/23/2024 - 2/29/2023, with 5 LPN's working day shift (6 AM-6 PM), 3 LPN's working night shift (6 PM-6 AM ), 1 Registered Nurse (RN) working day shift and 2 RN's working night shift. All confirmed they were educated and were aware of the processes for reconciliation across the continuum of care, administration of medications, anticoagulant management, the ACO PIP plan, and assistance available for any questions or concerns of discrepancy regarding medication. Review of the facility's corrective actions showed any licensed nurse, provider, or pharmacist not trained on the processes for reconciliation across the continuum of care, administration of medications, anticoagulant management, the ACO PIP plan, and assistance available for any questions or concerns of discrepancy regarding medication by 12/5/2023 would not be permitted to work until education was provided. Review of the facility's corrective actions showed all newly hired nurses, medical providers, or pharmacist will be trained on the policy and procedure prior to going on duty. The IJ was cited as past noncompliance and the facility is not required to submit a plan of correction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility contract, facility policy, medical record review, facility documentation and interviews, the facility failed to provide physician services to ensure 1 of 6 residents (Resident #5) reviewed for anticoagulation therapy received anticoagulation therapy for the diagnosis of Atrial Fibrillation and prevention of blood clot formation. Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified related to the facility's failure to ensure the physician reviewed the total program of care, including medications, which resulted in Resident #5 not receiving anticoagulation therapy from 10/31/2023-12/5/2023. On 11/9/2023, Resident #5's medications were reviewed by the Medical Director (MD) and the MD failed to recognize the resident had not received the anticoagulant therapy for the treatment of Atrial Fibrillation and prevention of blood clot formation from admission on [DATE]. On 12/5/2023, Nurse Practitioner (NP) #1 discovered Resident #5 was not on any anticoagulation therapy. Resident #5 was evaluated and assessed by the NP 12 times between 10/31/2023 and 11/30/2023 and the NP failed to recognize the resident had not received the anticoagulant therapy for the treatment of Atrial Fibrillation and prevention of blood clot formation. The Executive Director (ED) was notified of the Immediate Jeopardy (IJ) on 2/28/2024 at 4:20 PM, in the conference room. The facility was cited Immediate Jeopardy at F-711. The IJ was effective on 11/15/2023 and was removed on 12/5/2023. The facility's corrective actions were taken on 12/5/2023. The Immediate Jeopardy was cited as past non-compliance for F-711 and the facility is not required to submit a Plan of Correction. The findings include: Review of a facility contract titled, Performance Requirement & Practice Agreement, revised 1/3/2019, showed .NP [Nurse Practitioner #2] .Visits may alternate with a .NP .The physician may delegate to alternate the routine monthly visit or acute care visit to his/her nurse practitioner .Documentation in the patient's medical record will be comprehensive and will indicate a thorough examination and evaluation of the patient each visit . Review showed this contract was signed by NP #2 on 9/25/2019. Review of a facility contract titled, Performance Requirement & Practice Agreement, revised 9/1/2022, showed .NP #1 .Visits may alternate with a .NP .The physician may delegate to alternate the routine monthly visit or acute care visit to his/her nurse practitioner .Documentation in the patient's medical record will be comprehensive and will indicate a thorough examination and evaluation of the patient each visit . Review showed this contract was signed by NP #1 on 12/13/2022. Review of a facility contract titled,+ Performance Requirement & Practice Agreement, revised 9/1/2022, showed .MD [Medical Director] .The physician must visit and complete an initial comprehensive assessment .after admission .Documentation in the patient's medical record will be comprehensive and will indicate a thorough examination and evaluation of the patient each visit . Review showed this contract was signed by the MD on 1/18/2023. Review of a facility policy titled, Physician Services Guidelines, revised 3/10/2023, showed Documentation in the medical record must reflect supervision of the medical care of each patient in the facility .At the time of each visit, the physician must review the patient's total program of care, medications, treatments, and care plan . Resident #5 was admitted to the facility on [DATE], post hospitalization with diagnoses including Atrial Fibrillation, Long Term (Current) Use of Anticoagulants and Myocardial Infarction. Review of the hospital DISCHARGE SUMMARY for Resident #5 showed .discharge date : [DATE] .[on] 10/28/23 .INR [international normalized ratio] 1.6 .Discharge Medications .START taking these medications .apixaban [anticoagulant] 5 MG [milligram] .Commonly Known as Eliquis .1 tablet .2 .times a day .STOP taking these medications rivaroxaban [anticoagulant] 15 MG .Commonly known as Xarelto . Review of the hospital Discharge to Outside Facility Form for Resident #5 showed .10/31/23 Discharge Patient .Meds [medications] to Resume Upon Discharge .rivaroxaban 15 MG .2 .times a day with breakfast and dinner . Review of the admission Minimum Data Set (MDS) assessment, dated 11/2/2023, showed Resident #5's Brief Interview of Mental Status (BIMS) score was 3, indicating the resident had severe cognitive impairment and required assistance of one person with activities of daily living (ADL's). Review of the discharge MDS showed Resident #5 was discharged on 12/17/2023, to the hospital and did not return. Review of Resident #5's the facility progress notes from 10/31/2023-12/5/2023 showed the resident was seen by NP #1 12 times between 10/31/2023 - 11/30/2023. The NP documented .Reviewed meds . with each visit. Medical record review showed Resident #5 was seen by the MD on 11/9/2023 and the completed history and physical documented showed .Patient also had A-fib sick sinus syndrome [group of heart rhythm problems] .Eliquis was continued for stroke prophylaxis [preventative] .Available hospital records reviewed today. Medications and plan of care reviewed .Reviewed and appropriate . Review of the physician orders for Resident #5 showed Eliquis was ordered on 12/5/2023, 5 milligrams 2 times a day at 8:00 AM and 2:00 PM, for clot prevention. Documentation showed no orders for Xarelto, Eliquis, or any anticoagulant prior to 12/5/2023. Resident #5's NP #1 progress note, dated 12/5/2023, showed .History of Present Illness: Resident seen for acute reports of head pain .he was lying in bed, alert, no acute distress .Noted a small circular spongy area that seemed to be slightly discolored .No decrease in range of motion noted to neck .had concern for bleeding as resident is supposed to be on Eliquis twice daily. I performed a medication review to assess milligram [dose] and noted that resident's Eliquis was not on his MAR [medication administration record]. Given that resident had not had Eliquis since admission and given his symptoms with medical history it was best to send resident to ER [emergency room] for eval [evaluation] and treat . Review of the hospital ER records for Resident #5 showed .Date of Service 12/5/2023 4:15 PM .Chief Complaint .Neck Pain .No known injury .Patient cannot recall any trauma .Patient states that whenever he twists his neck to the left hurts the worst. No neurologic deficits noted .Neurological: Negative for weakness .He is not in acute distress .Patient likely with torticollis [condition in which the neck muscles contract]. Will discharge home with supportive treatment .CT [computed tomography] head .No CT evidence for acute intracranial abnormality .CT Cervical Spine .There is no acute fracture or dislocation . Review of a facility email from the Medical Director to the Executive Director (Administrator) dated 12/27/2023, concerning Resident #5 showed .On 10/31/2023 Patient [Resident #5] was discharged from the hospital and admitted to the nursing home .Upon arrival to the nursing home, all medications per discharge summary was continued. There was a question about anticoagulation, and the nurse discussed with the nurse practitioner, caring for the patient about anticoagulation issues per the nurse practitioner she gave directions to stop Xarelto and start Eliquis 5 mg [milligrams] bid [twice a day] However there was some confusion and the nurse felt that she received directions to stop Xarelto but was unsure if she had to resume Eliquis. Accordingly anticoagulation was not resumed from 10/31/2023 through 12/5/2023 when he went into the emergency room .CT scan on 12/5/23 showed no evidence of stroke or Bleeding/hemorrhagic changes in the brain at this point patient was discharged back to the nursing home and at this point anticoagulation with Eliquis was appropriately resumed on 12/5/2023 .It is certainly unfortunate that there was some miscommunication leading to anticoagulation not being resumed on 10/31/2023 . During an interview on 2/20/2024 at 11:00 AM, the DON stated .when he [Resident #5] came in on admission there was two different medicines which were 2 separate anticoagulants .the one that was in the admission packet was Xarelto and the one .brought [by EMS transporting Resident #5] which was the discharge summary orders .[for] Eliquis. So when the admitting nurse [License Practical Nurse (LPN) #1] saw this she called the nurse practitioner [NP #1] .asked her about having 2 of them [anticoagulants ordered] and the nurse practitioner told her to discontinue the Xarelto but never told her to go ahead and initiate the Eliquis .the nurse practitioner assumed he would still be getting the Eliquis .the provider [NP #1] had done several medication reviews on him and the pharmacy consultant did a medication review also and he didn't catch the discrepancy .On 12/5 [12/5/2023] he was complaining of neck pain and she [NP #1] realized he was not on Eliquis .the decision was made to send him to the hospital for further testing .the hospital .diagnosed him with torticollis . During an interview on 2/21/2024 at 10:30 AM, NP #1 stated .he [Resident #5] was supposed to be on Eliquis when he was admitted .I came over .looked at the papers with her [LPN #1] .I told her .start the Eliquis .[Resident #5] was complaining of neck pain at the back of his neck .when I discovered that it [Eliquis] had not been ordered .I sent him to the ER to do diagnostics .thorough work up .they [hospital] did a CT of his head and neck and there wasn't any findings of fractures, clots anything like that .sent back to the facility and he was started back on his Eliquis the same day that he went out to the ER and came back on the 5th [12/5/2023] .I did a PT/INR on him before he went to the ER .his INR was 1.7 and with someone with his medical history you would want it [INR] to be between 2 and 4 . During a telephone interview on 2/21/2024 at 11:40 AM, LPN #1 stated .there is always that one set of admission orders that they fax over to admissions [nurse] and I had them before EMS arrived .the faxed orders are the ones that we put in the system [Point Click Care (PCC) ] .all those orders were put in before he [Resident #5] got to the facility .the one [anticoagulant] that was on there was the Xarelto .when he arrived .the papers .brought with him said Xarelto and Eliquis .pharmacy called to see which one was .[to] be the one given. I told them I would call [NP #1] .she verbally told me over the phone to dc [discontinue] the Xarelto and she would reevaluate the next day .she did not go over the papers with me .she just said to dc the Xarelto and that was the last thing she said about it .I dc'd the Xarelto that she said to .the Eliquis wasn't on the faxed orders so it wasn't put in the system so when she said to dc the Xarelto he had no blood thinners [anticoagulant] at all ordered .I figured she would do what she said and reevaluate and she would put him on one [anticoagulant] the next day .once he started getting sick and he was sent out that's when they realized that he wasn't on any .he hadn't gotten any blood thinners from when he got there [10/31/2023] until he went out to the hospital [12/5/2023] . During a telephone interview on 2/23/2023 at 1:45 PM, the MD stated .that H and P [history and physical] review [on 11/9/2023] I dictated from the discharge summary from the hospital .I thought he was supposed to be stopped from the Xarelto and started on Eliquis and that was missed .I don't think I caught it .no I did not pick up on that .there could have been a thrombotic stroke that could have happened but it did not happen .it could be possible it could have happened from not being on the blood thinners for 4 to 5 weeks [Resident #5 did not receive anticoagulation therapy for the first 34 days of his stay] . During an interview on 2/26/2024 at 2:40 PM, the ED stated .the providers [physician (MD) and nurse practitioners] and the pharmacy consultant didn't catch that he [Resident #5] was not on an anticoagulant . The facility's corrective actions were validated onsite by the surveyor on 2/29/2024. The corrective action plan included a Root Cause Analysis (RCA), dated 12/5/2023, and was completed by the Executive Director and Director of Nursing on 12/5/2023. The facility's corrective actions were validated onsite by the surveyor on 2/29/2024. The corrective action plan included a Root Cause Analysis (RCA) and was completed by the Executive Director and Director of Nursing on 12/5/2023. Review of the RCA form, dated 12/5/2023, showed .Problem: [Resident #5] admitted with orders for Xarelto , however Eliquis mentioned in dc [discharge] summary. Admitting nurse [LPN #1] contacted NP [#1] for clarification and order given to d/c [discontinue] Xarelto. Resident [#5] seen by multiple providers on multiple occasions with medication reviews being done. On 12/5/23 resident was seen for neck pain and noted to not be on an ACO [anticoagulant]. At this point, concern noted about possible clot in head/neck area related to neck pain and resident not actively being on [Eliquis]. Provider [NP #1] assumed that nurse [LPN #1] would understand that Eliquis needed to be added to orders. Providers [NP's or MD] nor pharmacist caught this during medication review . Review of the RCA continued and showed 3 Why's were documented as follows: Why 1 Per providers, they do not review all medications. However, it is documented that all meds have been reviewed on several occasions. Per pharmacist, he conducted a thorough medication review and did not feel that this resident needed to be on an ACO per his review. Why 2 Providers and pharmacist failed to follow medication management, pharmacy services and medication regimen review, and physician services guideline policies. These policies were failed by failing to conduct a thorough medication review as outlined by these policies. Why 3 Root Cause Analysis Conclusion: Providers and pharmacist failed to follow facility policies which resulted in a failure to complete a thorough medication review. This resulted in this resident not being on an ACO. Review of Mobile Images report, dated 12/5/2023, for Resident #5 confirmed x-ray was performed at facility with no negative findings. Review of Mobile Images report, dated 12/5/2023, for Resident #5 confirmed Ultrasound was performed at facility with no negative findings. Review of facility Witness Interview/Statement Form dated 12/5/2023, confirmed the resident (#5)'s family was notified by the facility and the ER. Review of a Health Status Note dated 12/5/2023, for Resident #5 confirmed .PT/INR at this time PT 14.9 INR 1.2 . Review of NP #1's progress note dated 12/5/2023, for Resident #5 confirmed the resident was seen by provider. Review of the hospital ER report showed on 12/5/2023, Resident #5 was sent to ER for CT . Scan completed with .No CT evidence for acute intracranial abnormality . and the resident was diagnosed with Torticollis. Resident #5 was sent back to facility same day. Review of the RCA continued and showed, 2.) How will the facility identify other residents who have the potential to be affected by the same deficient practice? 2a.) Review of 100% of all residents on ACO-no issues identified. Person responsible Licensed Nurse Evaluation method Audit. Goal or Measure of Success and Date 12/5/2023 Evaluation Date/Results Bring findings to QAPI [Quality Assurance and Performance Improvement] Meeting. Review of ACO Audit 2A showed a list of 22 residents on ACO with ACO orders and resident care plans. The audit was completed on 12/5/2023 by the DON with no issues identified. Interview on 2/28/2023 at 3:00 PM with the DON confirmed 100% of residents on anticoagulation medication were reviewed on 12/5/2023 with no negative findings. 2b.) Review of ACO Meeting-no issues identified. Person responsible Licensed Nurse Evaluation method Audit Goal or Measure of Success and Date 12/5/202 Evaluation Date/Results Bring findings to QAPI Meeting. Review of the ACO Audit 2B showed ACO Meeting to ensure proper order for 100% of residents on ACO with 22 residents listed. Interview with the ED on 2/28/2023 at 3:15 PM, confirmed 100% of residents on ACO were brought to the impromptu QAPI meeting on 12/5/2023. 3.) What systemic change will be made to ensure the deficient process does not reoccur? On 12/5/2023 Provided education to Medical Director (MD)/Nurse Practitioners (providers) on Medication Reconciliation across the Continuum of Care policy. Physician Services Guidelines policy, Medication Management policy, ACO PIP [Performance Improvement Plan] and processes, entering orders expectation, medication review expectation, and Anticoagulation Management/Coumadin Therapy policy. Review of the facility's Education Acknowledgment form for the MD, NP#1, NP#2, and facility in-service sign in sheets showed the above education was completed on 12/5/2023. Telephone interview with NP #1 on 2/23/2023 12:30 PM, confirmed she was educated on the Medication Reconciliation across the Continuum of Care policy, Physician Services Guidelines policy, Medication Management policy, ACO PIP [Performance Improvement Plan] and was aware of the processes. Telephone interview with the MD on 2/23/2023 at 1:45 PM, confirmed she was educated on the Medication Reconciliation across the Continuum of Care policy, Physician Services Guidelines policy, Medication Management policy, ACO PIP [Performance Improvement Plan] and processes. Telephone interview with NP #2 on 2/23/2023 3:40 PM, confirmed she was educated on the Medication Reconciliation across the Continuum of Care policy, Physician Services Guidelines policy, Medication Management policy, ACO PIP and processes. Review of the facility's corrective actions showed any licensed nurse, provider, or pharmacist not trained on the processes for reconciliation across the continuum of care, administration of medications, anticoagulant management, the ACO PIP plan, and assistance available for any questions or concerns of discrepancy regarding medication by 12/5/2023 would not be permitted to work until education was provided. Review of the facility's corrective actions showed all newly hired nurses, medical providers, or pharmacist will be trained on the policy and procedure prior to going on duty. The IJ was cited as past noncompliance and the facility is not required to submit a plan of correction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility contract, facility policy, medical record review, facility documentation and interviews, the facility failed to complete a thorough medication regimen review to ensure 1 of 6 residents (Resident #5) reviewed for anticoagulation therapy received anticoagulation therapy for the diagnosis of Atrial Fibrillation and prevention of blood clot formation. Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified related to the facility's failure to provide anticoagulation therapy resulting in Resident #5 not receiving anticoagulation therapy from 10/31/2023 - 12/5/2023. The Executive Director (ED) was notified of the Immediate Jeopardy (IJ) on 2/28/2024 at 4:20 PM, in the conference room. The facility was cited Immediate Jeopardy at F-711. The IJ was effective on 11/15/2023 and was removed on 12/5/2023. The facility's corrective actions were taken on 12/5/2023. The Immediate Jeopardy was cited as past non-compliance for F-711 and the facility is not required to submit a Plan of Correction. The findings include: Review of the facility contract titled, PHARMACY CONSULTANT AGREEMENT, showed .as of July 1, 2017 .RESPONSIBILITIES OF PHARMACY .Consultant shall identify any irregularities as defined in the State Operations Manual .Consultant will provide a summary report .which (a) documents that no irregularity as identified, or (b) reports any irregularities . Review of the facility policy titled, Pharmacy Services and Medication Regimen Review, reviewed 8/28/2023, showed .The facility maintains the resident's highest practicable level of physical .well-being and .minimizes adverse consequences related to medication therapy to the extent possible, by providing oversight by a licensed pharmacist .The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing . Review of the medical record showed Resident #5 was admitted to the facility on [DATE] with diagnoses including Atrial Fibrillation, Long Term (Current) Use of Anticoagulants and Myocardial Infarction. Review of hospital DISCHARGE SUMMARY documentation (sent with the resident) for Resident #5 showed .discharge date : [DATE] .Discharge Medications .START taking these medications .apixaban [anticoagulant] 5 MG [milligram] .Commonly Known as Eliquis .1 tablet .2 .times a day .STOP taking these medications rivaroxaban [anticoagulant] 15 MG .Commonly known as Xarelto . Review of hospital Discharge to Outside Facility Form documentation (sent to the nursing home prior to the hospital discharge) for Resident #5 showed .10/31/23 Discharge Patient .[to named facility] .Meds [medications] .rivaroxaban 15 MG .2 .times a day with breakfast and dinner . Review of the admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #5's Brief Interview of Mental Status (BIMS) score was 3, indicating the resident had severe cognitive impairment. The resident required assistance of one person with activities of daily living (ADL's). Review of the MDS discharge assessment showed Resident #5 was discharged to the hospital on [DATE] and did not return. Review of a pharmacy consultation report for Resident #5 dated 11/20/2023, showed .To: Medical Director [MD]; [Director of Nursing (DON)] From: [Pharmacy Consultant] .Recommendation: Please discontinue Glipizide [antidiabetic] . No documentation of irregularities or mention of conflicting orders for anticoagulation were noted and the report was signed by the MD on 12/1/2023 and DON on 12/7/2023. Review of physician orders for Resident #5 showed Eliquis was ordered on 12/5/2023, 5 milligrams 2 times a day at 8:00 AM and 2:00 PM, for clot prevention. Documentation showed no orders for Xarelto, Eliquis, or any anticoagulant prior to 12/5/2023. Review of Facility's progress notes for Resident #5 showed .12/5/2023 .PT/INR at this time, PT 14.9 INR 1.2 . Review of the facility's MOBILE IMAGES report for Resident #5 showed .12/05/2023 .Ultrasound exam of head and neck .There is no evidence of mass or hematoma [pool of mostly clotted blood] involving the left occipital [back of the head] area .12/05/2023 .SKULL SERIES, 3 VIEWS .No intrinsic bony abnormality is identified .12/05/2023 . SPINE, CERVICAL 2-3 VIEWS .No fracture or other acute findings identified . Review of Resident #5's Nurse Practitioner (NP) #1 note dated 12/5/2023, showed .History of Present Illness: Resident seen for acute reports of head pain .he was lying in bed, alert, no acute distress .Noted a small circular spongy area that seemed to be slightly discolored .No decrease in range of motion noted to neck .had concern for bleeding as resident is supposed to be on Eliquis twice daily. I performed a medication review to assess milligram and noted that resident's Eliquis was not on his MAR [medication administration record]. Given that resident had not had Eliquis since admission and given his symptoms with medical history it was best to send resident to ER [emergency room] . Review of the hospital ER records for Resident #5 showed .Date of Service 12/5/2023 4:15 PM .Chief Complaint .Neck Pain .No known injury .Patient cannot recall any trauma .Patient states that whenever he twists his neck to the left hurts the worst. No neurologic deficits noted .Neurological: Negative for weakness .He is not in acute distress .Will discharge home with supportive treatment .CT [computed tomography] head .No CT evidence for acute intracranial abnormality .CT Cervical Spine .There is no acute fracture or dislocation . During an interview on 2/20/2024 at 11:00 AM, the DON stated .when he [Resident #5] came in on admission there was two different medicines which were 2 separate anticoagulants .the one that was in the admission packet was Xarelto and the one .brought [with the resident by EMS (emergency medical services)] which was the discharge summary orders [for] .Eliquis. So when the admitting nurse [License Practical Nurse [( LPN) #1] saw this she called the nurse practitioner [NP #1] .asked her about having 2 of them [anticoagulants ordered] and the nurse practitioner told her to discontinue the Xarelto but never told her to go ahead and initiate the Eliquis .the nurse practitioner assumed he [Resident #5] would still be getting the Eliquis .and the pharmacy consultant did a medication review [for Resident #5] .and he didn't catch the discrepancy . During an interview on 2/21/2024 at 10:30 AM, NP #1 stated .he was supposed to be on Eliquis when he was admitted .I came over .looked at the papers with her [LPN #1] .I told her .start the Eliquis .[Resident #5] was complaining of neck pain at the back of his neck .when I discovered that it [Eliquis] had not been ordered .he was started back on his Eliquis the same day that he went out to the ER and came back on the 5th [12/5/2023] .I did a PT/INR on him before he went to the ER .his INR was 1.7 and with someone with his medical history you would want it [INR] to be between 2 and 4 . During a telephone interview on 2/21/2024 at 11:40 AM, LPN #1 stated .there is always that one set of admission orders that they fax over to admissions [nurse] and I had them before EMS arrived .the faxed orders are the ones that we put in the system [Point Click Care (PCC) ] .all those orders were put in before he [Resident #5] got to the facility .the one [anticoagulant] that was on there was the Xarelto .when he arrived .the papers .brought with him said Xarelto and Eliquis .pharmacy called to see which one was .[to] be the one given. I told them I would call [NP #1] .she verbally told me over the phone to dc [discontinue] the Xarelto and she would reevaluate the next day .she did not go over the papers with me .she just said to dc [discontinue] the Xarelto and that was the last thing she said about it .I dc'd the Xarelto that she said to .the Eliquis wasn't on the faxed orders so it wasn't put in the system so when she said to dc the Xarelto he had no blood thinners [anticoagulant] at all ordered .I figured she would do what she said and reevaluate and she would put him on one [anticoagulant] the next day . During a telephone interview on 2/23/2024 at 1:15 PM, the Pharmacy Consultant stated .as the Consultant I just do monthly reviews .with the orders that come across if an order doesn't get entered in PCC the pharmacist at the pharmacy would have no way of knowing that and I would not see it until the regular monthly review .main thing I'm looking at is if it's a new admission I will look at the admission orders .I would have looked at the orders what they are on currently what changes were made and why .I did not notice the discrepancy I did look at both documents .I look at the diagnoses too .yes, I look at the H&P [history and physical], new orders, and a discharge summary .I honestly don't know how it got missed . During an interview on 2/26/2024 at 2:40 PM, the ED stated .the providers [physician (MD) and nurse practitioners] and the pharmacy consultant didn't catch that he [Resident #5] was not on an anticoagulant . The facility's corrective actions were validated onsite by the surveyor on 2/29/2024. The corrective action plan included a Root Cause Analysis (RCA) and was completed by the Executive Director and Director of Nursing on 12/5/2023. Review of the RCA form dated 12/5/2023, showed .Problem: [Resident #5] admitted with orders for Xarelto [anticoagulant ], however, Eliquis [anticoagulant] mentioned in dc [discharge] summary. Admitting nurse contacted NP [#1] for clarification and order given to d/c [discontinue] Xarelto. Resident [#5] seen by multiple providers on multiple occasions with medication reviews being done. On 12/5/2023 resident was seen for neck pain and noted to not be on an ACO [anticoagulant]. At this point, concern noted about possible clot in head/neck area related to neck pain and resident not actively being on [Eliquis]. Provider [NP #1] assumed that nurse [LPN #1] would understand that Eliquis needed to be added to orders. Providers nor pharmacist caught this during medication review . Review of the RCA continued and showed 3 Why's were documented as follows: Why 1 Per providers, they do not review all medications. However, it is documented that all meds have been reviewed on several occasions. Per pharmacist, he conducted a thorough medication review and did not feel that this resident needed to be on an ACO per his review. Why 2 Providers and pharmacist failed to follow medication management, pharmacy services and medication regimen review, and physician services guideline policies. These policies were failed by failing to conduct a thorough medication review as outlined by these policies. Why 3 Root Cause Analysis Conclusion: Providers and pharmacist failed to follow facility policies which resulted in a failure to complete a thorough medication review. This resulted in this resident not being on an ACO. Review of Mobile Images patient report dated 12/5/2023, for Resident #5 confirmed x-ray was performed at facility with no negative findings. Review of Mobile Images patient report dated 12/5/2023, for Resident #5 confirmed Ultrasound was performed at facility with no negative findings. Review of facility Witness Interview/Statement Form dated 12/5/2023, confirmed the resident (#5)'s family was notified by the facility and the ER. Review of a Health Status Note dated 12/5/2023, for Resident #5 confirmed .PT/INR at this time PT 14.9 INR 1.2 . Review of NP #1's progress note dated 12/5/2023, for Resident #5 confirmed the resident was seen by provider. Review of hospital emergency department documentation dated 12/5/2023 confirmed a CT was completed with No CT evidence for acute intracranial abnormality resident was diagnosed with Torticollis and sent back to the facility. Review of the RCA continued and showed, 2.) How will the facility identify other residents who have the potential to be affected by the same deficient practice? 2a.) Review of 100% of all residents on ACO-no issues identified. Person responsible Licensed Nurse Evaluation method Audit. Goal or Measure of Success and Date 12/5/2023 Evaluation Date/Results Bring findings to QAPI [Quality Assurance and Performance Improvement] Meeting. Review of ACO Audit 2A showed a list of 22 residents on ACO with ACO orders and resident care plans. The audit was completed on 12/5/2023 by the DON with no issues identified. Interview on 2/28/2023 at 3:00 PM with the DON confirmed 100% of residents on anticoagulation medication were reviewed on 12/5/2023 with no negative findings. 2b.) Review of ACO Meeting-no issues identified. Person responsible Licensed Nurse Evaluation method Audit Goal or Measure of Success and Date 12/5/202 Evaluation Date/Results Bring findings to QAPI Meeting. Review of the ACO Audit 2B showed ACO Meeting to ensure proper order for 100% of residents on ACO with 22 residents listed. Interview with the ED on 2/28/2023 at 3:15 PM, confirmed 100% of residents on ACO were brought to the impromptu QAPI meeting on 12/5/2023. 3.) What systemic change will be made to ensure the deficient process does not reoccur? On 12/5/2023 Provided education to Medical Director (MD)/Nurse Practitioners (providers) on Medication Reconciliation across the Continuum of Care policy. Physician Services Guidelines policy, Medication Management policy, ACO PIP [Performance Improvement Plan] and processes, entering orders expectation, medication review expectation, and Anticoagulation Management/Coumadin Therapy policy. Review of the facility's Education Acknowledgment Form for the MD, NP #1, NP #2, and facility in-service sign in sheets showed the above education was completed on 12/5/2023. Review of the facility's corrective actions showed on 12/5/2023, education was provided to the Pharmacist on Pharmacy Services and Medication Regimen Review policy, Medication Reconciliation Across the Continuum of Care policy, ACO PIP plan and processes, and medication review expectations. Review of facility's Education Acknowledgment Form for the Pharmacy Consultant showed the above education was completed on 12/5/2023. Telephone interview on 2/23/2024 at 2:30 PM, with the Pharmacy Consultant confirmed he was educated as the facility documentation review showed and was aware of the processes. Review of the facility's corrective actions showed any licensed nurse, provider, or pharmacist not trained on the processes for reconciliation across the continuum of care, administration of medications, anticoagulant management, the ACO PIP plan, and assistance available for any questions or concerns of discrepancy regarding medication by 12/5/2023 would not be permitted to work until education was provided. Review of the facility's corrective actions showed all newly hired nurses, medical providers, or pharmacists will be trained on the policy and procedure prior to going on duty. The IJ was cited as past noncompliance and the facility is not required to submit a plan of correction.