Based on interview and record review, the facility did not consult with resident's physician or extender when 1 of 3 residents (R1) had a significant change in her medical condition. R1 was receiving an anticoagulant medication and experienced a change in condition when RN C (Registered Nurse) used a Q-tip to remove hard wax from R1's ears. R1's ears began to bleed, and RN C did not contact R1's Medical Doctor (MD) or an on-call MD when R1 had this change in condition. RN H also did not contact R1's MD or an on-call MD regarding uncontrolled bleeding when she became aware. All of this resulted in R1 being sent to the emergency room where she received medical intervention to control bleeding. Evidenced by: Facility policy, entitled Anticoagulant Use Policy, dated 7/20/22, includes in part: when taking warfarin, the international normalized ratio is monitored as ordered to be sure medication is given as therapeutic dose . residents who are taking anticoagulants will have a care plan stating that they are taking the Med and what adverse effects (bleeding) that nursing staff should be monitoring for. signs of adverse bleeding may be bruising without obvious cause, head injury, severe or prolonged headache, hematuria, prolonged bleeding from small cuts, etc. MD should be updated if the above are noted . Facility policy, entitled Resident Change in Condition Policy and Procedure, dated 8/7/22, includes in part: .in the long-term care setting a primary goal of identifying an acute change in condition is to enable staff to evaluate and manage a patient at the facility and avoid transfer to a hospital or emergency room. to achieve this goal the facility staff must recognize an acute change in condition and identify its nature, severity, and cause. Physicians are notified of changes in resident condition. Procedure: if a nurse notices a change in condition she or he should assess the resident to determine the nature, severity, and possible cause of the change. The nurse should determine from the suggested Guidelines for physician notification of clinical problems in facility residence grid if and when the resident's attending physician or on call physician needs to be notified. Abrasion . immediate: accompanied by significant pain or bleeding . non-immediate: if bleeding continues or if associated with evidence of local infection . Injuries and complaints . immediate: abrupt onset of severe pain secondary to fall or injury . hematuria . immediate: gross hematuria with pain . puncture wounds . immediate: deep or open wound . note these are general guidelines which cannot anticipate all circumstances. a nurse should not hesitate to call anytime a situation is unclear or if a physician support is felt to be needed. The National Institute of Health, Drug Information Portal, U.S. National Library of Medicine, last updated 7/25/2022, includes, in part: . TXA or Tranexamic Acid is a medication used to treat or prevent excessive blood loss from major trauma, postpartum bleeding, surgery, tooth removal, nosebleeds, and heavy menstruation . Indications: The only FDA-approved usage for tranexamic acid (TXA) is for heavy menstrual bleeding and short-term prevention in patients with hemophilia. R1's most recent admission to the facility was on 6/11/2021. Her diagnoses include: chronic congestive heart failure, atrial fibrillation, pulmonary hypertension, and longtime anticoagulant therapy. R1's most recent Minimum Data Set (MDS), with Assessment Reference Date (ARD) of 3/28/23, indicates R1 is cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. R1's Comprehensive Care Plan, initiated 3/8/2019, includes in part: problem - potential for uncontrolled bleeding related to longtime anti-coagulant therapy, atrial fibrillation, pulmonary hypertension, and heart failure. Manifested by bleeding, recent bloody nose unable to control and recent hospitalization . approach - nurses assess condition after incidents . administer anticoagulant as ordered . report to MD as needed, assess any bleeding, observe/monitor for bleeding and adverse reactions of warfarin . Update MD if above are noted . nurse aide report any bleeding . goal - no uncontrolled bleed . R1's Physician Orders, January 2023, include in part: start date: 11/09/22 - Warfarin 1 mg by mouth every Tuesday, Thursday, Saturday, Sunday . start date: 11/09/22 -Warfarin 6mg by mouth every Monday, Wednesday, Friday . start date:11/09/22 - Carbamide Peroxide 6.5% . 3 drops two times a day each ear to remove ear wax as needed . R1's Nurse Notes include: 1/6/23 at 1:34 PM Writer was able to remove large hard chunk of cerumen from both ear canals. Wax was visibly blocking outer ear canals. Resident said she did not get ear drops in last night before bed. Writer was able to use Q tip gently to remove hard wax from canal and writer was able to see tympanic membrane without difficulty. Ears cleaned out before lunch. During lunch resident requested cotton balls be placed in outer ear because they were bleeding. Writer updated DON B (Director of Nursing) on bleeding and after lunch writer used warm water in ear flusher to rinse out both outer ears and used dry washcloth to clean outer ears. Writer encouraged resident to leave her ears alone and not put anything in them so they can heal. Will continue to monitor. Signed RN C (Registered Nurse). (It is important to note neither RN C, nor DON B contacted R1's MD when she had a change in condition / bleeding and pain in her ear.) 1/6/23 at 9:38 PM behaviors occurred: No 1/7/23 at 7:15 AM called into patients room at 6:15 AM to assess, as nurse entered room patient is lying in bed on her back, walked around to the right side of her bed and noted copious amounts of wet blood saturated through pillowcase and pillow, onto sheets through onto mattress {sic}, noted a 4 by 4 gauze packed into right ear completely saturated with blood and with large dried blood clot, used a warm wet washcloth to moisten and remove the packing from right ear, noted ear still actively bleeding and placed a cotton ball into the opening of the ear canal. Resident stated, I was supposed to have my ear flushed yesterday after receiving debrox drops to remove the wax and (RN C) dug hard into my ear with several Q-tips just before lunch and kept digging and digging . and then after lunch she flushed my ear with water and it was still bleeding. call place to MD updated on findings from nurse note yesterday 1/6/23 and right ear continues with bleeding and concerns that resident is on 6 milligrams of warfarin daily. order received to transfer resident to local hospital ER for evaluation. 1/7/23 at 7:26 AM call place 911 for ambulance transport and resident's daughter per resident's request to update {sic}. 1/7/23 at 7:36 AM cotton ball nearly saturated with blood again at this time, left cotton ball in place and placed 4 by 4 gauze over her right ear . 1/7/23 at 8:03 AM writer placed hand over resident's left ear to check hearing of right ear and resident reported, not able to hear you as well. 1/7/23 at 8:04 AM prior to leaving facility resident requested to do a formal complaint. message left with SW G (Social Worker) and DON B. 1/7/23 at 1:08 PM R1 returned from ER visit. 1/7/23 at 1:55 PM R1 returned from ER visit for bleeding ear via ambulance. TXA (tranexamic acid) was used in ear to alleviate bleeding. Cotton ball in place to right ear upon return. Assisted off stretcher and into wheelchair. INR checked in ER with result being 2.4. New order to hold warfarin tonight 1/7 and tomorrow 1/8, repeat INR Monday 1/9. Leave cotton balls in the ear and change it once daily (can change cotton ball anytime saturated per MD). (It is important to note according to Drug Information Portal. U.S. National Library of Medicine, TXA or Tranexamic Acid is a medication used to treat or prevent excessive blood loss from major trauma, postpartum bleeding, surgery, tooth removal, nosebleeds, and heavy menstruation.) R1's Nurse Note, 1/7/23 at 2:41 PM, includes, Per nurse to nurse with ER nurse and facility nurse, it was reported that R1's eardrum was not compromised but there was an abrasion present . R1 admits to pain inside my ear. R1's ER Notes, dated 1/7/23, include, in part: . history of hyperthyroidism, hypertension, atrial fibrillation, and on Coumadin presenting for bleeding from the right ear. Patient reports she has been with significant earwax which has been treated with drops although yesterday afternoon (a staff member) used a Q-tip and subsequently was bleeding from the right ear. Patient reports her most recent INR was over 3. Patient reports they were unable to achieve hemostasis at her facility for which she was sent to the Emergency Department . Right external auditory canal with slight oozing of bright red blood. Tympanic membrane is slightly obscured although visualized aspect appears intact. Emergency Department Course - history of hyperthyroidism, hypertension, atrial fibrillation, and on Coumadin presenting for bleeding from the right ear secondary to trauma from a Q-tip. Upon arrival patient is hemodynamically stable and nontoxic. Patient has slight bleeding from the right external auditory canal and visualized aspect of the tympanic membrane appears intact. Gauze soaked in TXA (tranexamic acid) were packed into the right ear. Today your INR was 2.4. Given the bleeding from your ear do not take your Coumadin tonight or tomorrow night. You may resume your Coumadin on Monday if bleeding has stopped. Also recheck your INR Monday. Leave the current cotton balls in the ear and change it once daily. Tomorrow morning it is okay if the ear is bleeding just reapply cotton ball. If there is continued active bleeding on Monday return to the ER for evaluation. On 5/11/23 at 10:38 AM during an interview, CNA E (Certified Nursing Assistant) indicated on 1/6/23 she observed RN C go into R1's room with a handful of Q-tips before lunch. CNA E indicated right after lunch she observed R1's ears to be bleeding. CNA E indicated RN C stated, Oh my God (R1's) ears are bleeding, and took R1 into her room. CNA E then saw RN C return to the hallway with a handful of blood-stained washcloths. CNA E indicated R1 wanted to speak to DON B about this and CNA F and CNA E pushed R1 to DON B's office. In DON B's office R1 stated RN C hurt her ear and was digging and digging in her ear. R1 stated she asked RN C to stop, and she did not stop. CNA E indicated on 1/7/23, R1 was found lying in bed in a pool of blood that saturated the bedding, R1's pajamas, and the pillow. CNA E indicated there was now 4x4 gauze packed in R1's ear that was saturated and had large clots on it. CNA E stated LPN D came in the room and pulled out the 4x4 gauze from R1's right ear and more blood gushed out and at this time R1 stated, I want to file a formal complaint. I thought I did this yesterday. I told her it hurt, and she dug and dug and dug and wouldn't stop. Q-tips don't belong inside the ear. CNA E indicated R1 went to the ER on the morning of 1/7/23 and when she came back R1 was saying her ear still hurt and she was very upset. CNA E added at the end of interview, When someone tells me to stop, I stop. My primary residents are family to me. I was upset because R1 was in so much pain. On 5/11/23 at 11:58 AM, LPN D indicated on 1/7/23 at 6:15 AM CNA F called her to come to R1's room due to her lying in an excessive amount of blood. LPN D indicated she observed R1 bleeding from her right ear and 4x4 gauze packed in her ear. LPN D indicated blood clots could be seen on the gauze and on the pillow, the blood had soaked through R1's hair, the sheets, pillowcase, pillow, R1's pajamas, and pooled onto R1's mattress. LPN D indicated she received report in the morning before coming onto the floor and nothing was said about R1 and her ears. LPN D indicated she read through R1's nurse notes from 1/6/23 and noticed R1 was already bleeding then, and her MD was never notified, and no RN assessment was completed. LPN D indicated she called R1's MD and got an order for her to go to ER right away because, I knew she was on Warfarin. I removed the 4x4 to see what was going on and it was still bleeding. I repacked it. I called MD on call. I was embarrassed to report that R1's ears were supposed to be irrigated yesterday. I never dig in anyone's ear with anything. LPN D indicated she reported immediately to DON B because she was the RN on call and when someone tells her to stop, she stops. On 5/11/23 at 12:02 PM during an interview, RN C indicated she was aware R1 was on an anticoagulant. RN C indicated she was also aware R1's ears were bleeding after RN C used a q tip to clean out R1's ears. RN C indicated she did not complete an RN assessment that included the source of the blood, the amount of the blood, the color of the blood, vital signs, and pain level of R1's pain. RN C indicated she placed a cotton ball in R1's ears. RN C indicated she did not recall if R1 had asked her to stop due to pain in her ear. RN C stated, I did not call R1's Medical Doctor to consult with him after the incident and I should have. On 5/10/23 at 12:06 PM, CNA F indicated on 1/6/23 before lunch she saw RN C going in to R1's room with Q-tips to flush R1's ears. She saw R1 coming back from lunch and her ears were bleeding. CNA F indicated R1 was on coumadin at that time and was at a higher risk for uncontrolled bleeding. CNA F indicated RN C probably should have reported the bleeding to R1's MD right away especially with the blood thinner. CNA F indicated she observed RN C carrying blood-stained washcloths from R1's room after lunch. CNA F indicated the next day she found R1 in a pool of blood and it was a mess. CNA F got LPN D right away and there was 4x4 gauze packed in R1's ears that the night shift nurse must have put in there. When LPN D pulled the packing out of ear there was a big clot and blood everywhere. CNA F indicated R1 reported that she had told RN C to stop digging in her ears, but she wouldn't stop. CNA F stated, They didn't say anything about it to us in report that morning. I walked in and was in shock. RN C and RN H knew about it because the nurse put packing in her ears. (It is important to note RN H did not contact R1's MD regarding uncontrolled bleeding, pain, and the injury R1 sustained in her ear.) On 5/10/23 at 1:00 PM during an interview, R1 stated, I was using drops for 5 days and 5th day they were supposed to flush them. RN C took a Q-tip and dug and dug and dug. I told her to stop, and she said we must get that out of there. She kept at it. It bled for a long time and a lot after that. She was only supposed to flush it and not stick anything in there. I don't know if she contacted my doctor. The other nurse came in and put stuff in there. I am on coumadin. They had to change my pillowcase throughout the night because of it. They are supposed to call my doctor if I have bleeding anywhere. I don't let her near me to do anything like that again, but I do take medications from her. On 5/10/23 at 1:27 PM, DON B indicated RN C, RN H, and/or DON B should have notified R1's MD when she was injured, was bleeding with verbal reports of pain, and when bleeding was uncontrolled, and they didn't.

Based on interview and medical record review, facility staff did not provide care and treatment in accordance with professional standards of practice for 1 of 3 sampled residents (R1) R1 was receiving an anticoagulant medication and experienced a change in condition when RN C used a Q-tip to remove hard wax from R1's ears and R1's ears began to bleed. RN C (Registered Nurse) did not stop when R1 verbally expressed pain and said Stop, did not complete an RN assessment after an injury was noted, did not contact R1's Medical Doctor (MD) or an on-call MD. RN H, the night shift nurse, did not contact R1's MD or an on-call MD regarding uncontrolled bleeding when she became aware, did not perform an RN assessment, and did not pass on R1's change in condition to the next shift for continued monitoring. All of this resulted in R1 being sent to the emergency room where she received medical intervention to control bleeding. Evidenced by: Facility policy, entitled Anticoagulant Use Policy, dated 7/20/22, includes, in part: when taking warfarin, the international normalized ratio is monitored as ordered to be sure medication is given as therapeutic dose . residents who are taking anticoagulants will have a care plan stating that they are taking the Med and what adverse effects (bleeding) that nursing staff should be monitoring for. signs of adverse bleeding may be bruising without obvious cause, head injury, severe or prolonged headache, hematuria, prolonged bleeding from small cuts, etc. MD should be updated if the above are noted . Facility policy, entitled Resident Change in Condition Policy and Procedure, dated 8/7/22, includes, in part: . in the long-term care setting a primary goal of identifying and acute change in condition is to enable staff to evaluate and manage a patient at the facility and avoid transfer to a hospital or emergency room. to achieve this goal the facility staff must recognize an acute change in condition and identify its nature, severity, and cause. Physicians are notified of changes in resident condition. Procedure: if a nurse notices a change in condition she or he should assess the resident to determine the nature, severity, and possible cause of the change. The nurse should determine from the suggested Guidelines for physician notification of clinical problems in facility residence grid if and when the resident's attending physician or on call physician needs to be notified. Abrasion . immediate: accompanied by significant pain or bleeding . non-immediate: if bleeding continues or if associated with evidence of local infection . Injuries and complaints . immediate: abrupt onset of severe pain secondary to fall or injury . hematuria . immediate: gross hematuria with pain . puncture wounds . immediate: deep or open wound . note these are general guidelines which cannot anticipate all circumstances. a nurse should not hesitate to call anytime a situation is unclear or if a physician support is felt to be needed. The National Institute of Health, Drug Information Portal, U.S. National Library of Medicine, last updated 7/25/2022, includes, in part: . TXA or Tranexamic Acid is a medication used to treat or prevent excessive blood loss from major trauma, postpartum bleeding, surgery, tooth removal, nosebleeds, and heavy menstruation . Indications: The only FDA-approved usage for tranexamic acid (TXA) is for heavy menstrual bleeding and short-term prevention in patients with hemophilia. R1's most recent admission to the facility was on 6/11/21. Her diagnoses include: chronic congestive heart failure, atrial fibrillation, pulmonary hypertension, and longtime anticoagulant therapy. R1's most recent Minimum Data Set (MDS), with Assessment Reference Date (ARD) of 3/28/23, indicates R1 is cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. R1's Comprehensive Care Plan, initiated 3/8/19, includes, in part: problem- potential for uncontrolled bleeding related to longtime anti-coagulant therapy, atrial fibrillation, pulmonary hypertension, and heart failure. Manifested by bleeding, recent bloody nose unable to control and recent hospitalization . approach- nurses assess condition after incidents . administer anticoagulant as ordered . report to MD as needed, assess any bleeding, observe/monitor for bleeding and adverse reactions of warfarin . Update MD if above are noted . nurse aid report any bleeding . goal- no uncontrolled bleed . R1's Physician Orders, January 2023, include in part: start date: 11/09/22- Warfarin 1 mg by mouth every Tuesday, Thursday, Saturday, Sunday . start date: 11/09/22-Warfarin 6mg by mouth every Monday, Wednesday, Friday . start date:11/09/22- Carbamide Peroxide 6.5% . 3 drops two times a day each ear to remove ear wax as needed . R1's Nurse Notes include: 1/6/23 at 1:34 PM Writer was able to remove large hard chunk of cerumen from both ear canals. Wax was visibly blocking outer ear canals. Resident said she did not get ear drops in last night before bed. Writer was able to use Q-tip gently to remove hard wax from canal and writer was able to see tympanic membrane without difficulty. Ears cleaned out before lunch. During lunch resident requested cotton balls be placed in outer ear because they were bleeding. Writer updated DON B (Director of Nursing) on bleeding and after lunch writer used warm water in ear flusher to rinse out both outer ears and used dry washcloth to clean outer ears. Writer encouraged resident to leave her ears alone and not put anything in them so they can heal. Will continue to monitor. Signed RN C. (It is important to note when R1 was noted to be bleeding from her ears an RN Assessment was not completed, including a description of the amount of blood, the color of blood, and the source of blood.) (It is important to note RN H was the night shift nurse the facility provided no documentation as to R1's condition through the night and RN H did not return call to Surveyor during Survey. The facility failed to provide evidence of RN H completing an RN assessment or updating R1's MD with her uncontrolled bleeding.) 1/7/23 at 7:15 AM called into patients room at 6:15 AM to assess, as nurse entered room patient is lying in bed on her back, walked around to the right side of her bed and noted copious amounts of wet blood saturated through pillowcase and pillow, onto sheets through onto mattress, noted a 4 by 4 gauze packed into right ear completely saturated with blood and with large dried blood clot, used a warm wet washcloth to moisten and remove the packing from right ear, noted ear still actively bleeding and placed a cotton ball into the opening of the ear canal. Call place to MD updated on findings from nurse note yesterday 1/6/23 and right ear continues with bleeding and concerns that resident is on 6 milligrams of warfarin daily. Order received to transfer resident to local hospital ER for evaluation. 1/7/23 at 7:26 AM call placed to 911 for ambulance transport and resident's daughter per resident's request to update. 1/7/23 at 7:36 AM cotton ball nearly saturated with blood again at this time, left cotton ball in place and placed 4 by 4 gauze over her right ear . 1/7/23 at 1:55 PM R1 returned from ER visit for bleeding ear via ambulance. TXA (tranexamic acid) was used in ear to alleviate bleeding. New order to hold warfarin tonight 1/7 and tomorrow 1/8, repeat INR Monday 1/9. Leave cotton balls in the ear and change it once daily (can change cotton ball anytime saturated per MD). (It is important to note according to Drug Information Portal. U.S. National Library of Medicine, TXA or Tranexamic Acid is a medication used to treat or prevent excessive blood loss from major trauma, postpartum bleeding, surgery, tooth removal, nosebleeds, and heavy menstruation.) 1/7/23 at 2:41 PM Per nurse to nurse with ER nurse and facility nurse, it was reported that R1's eardrum was not compromised but there was an abrasion present . R1 admits to pain inside my ear. R1's ER Notes, dated 1/7/23, include, in part: .history of hyperthyroidism, hypertension, atrial fibrillation, and on Coumadin presenting for bleeding from the right ear. Patient reports she has been with significant earwax which has been treated with drops although yesterday afternoon (a staff member) used a Q-tip and subsequently was bleeding from the right ear. Patient reports her most recent INR was over 3. Patient reports they were unable to achieve hemostasis at her facility for which she was sent to the Emergency Department . Right external auditory canal with slight oozing of bright red blood. Tympanic membrane is slightly obscured although visualized aspect appears intact. Emergency Department Course- history of hyperthyroidism, hypertension, atrial fibrillation, and on Coumadin presenting for bleeding from the right ear secondary to trauma from a Q-tip. Upon arrival patient is hemodynamically stable and nontoxic. Patient has slight bleeding from the right external auditory canal and visualized aspect of the tympanic membrane appears intact. Gauze soaked in TXA (tranexamic acid) were packed into the right ear. Today your INR was 2.4. Given the bleeding from your ear do not take your Coumadin tonight or tomorrow night. You may resume your Coumadin on Monday if bleeding has stopped. Also recheck your INR Monday. Leave the current cotton balls in the ear and change it once daily. Tomorrow morning it is okay if the ear is bleeding just reapply cotton ball. If there is continued active bleeding on Monday return to the ER for evaluation. On 5/11/23 at 10:38 AM, during an interview, CNA E indicated on 1/6/23 she observed RN C go into R1's room with a handful of Q-tips before lunch. CNA E indicated right after lunch she observed R1's ears to be bleeding. CNA E indicated RN C stated, Oh my God (R1's) ears are bleeding, and took R1 into her room. CNA E then saw RN C return to the hallway with a handful of blood-stained washcloths. CNA E indicated R1 wanted to speak to DON B about this and CNA F and CNA E pushed R1 to DON B's office. In DON B's office R1 stated RN C hurt her ear and was digging and digging in her ear. R1 stated she asked RN C to stop, and she did not stop. CNA E indicated on 1/7/23 R1 was found lying in bed in a pool of blood that saturated the bedding, R1's pajamas, and the pillow. CNA E indicated there was now 4x4 gauze packed in R1's ear that was saturated and had large clots on it. CNA E stated LPN D came in the room and pulled out the 4x4 gauze from R1's right ear and more blood gushed out and at this time R1 stated, CNA E indicated R1 went to the ER on the morning of 1/7/23 and when she came R1 was saying her ear still hurt and she was very upset. On 5/11/23 at 11:58 AM LPN D indicated on 1/7/23 at 6:15 AM CNA F called her to come to R1's room due to her lying in an excessive amount of blood. LPN D indicated she observed R1 bleeding from her right ear and 4x4 gauze packed in her ear. LPN D indicated blood clots could be seen on the gauze and on the pillow, the blood had soaked through R1's hair, the sheets, pillowcase, pillow, R1's pajamas, and pooled onto R1's mattress. LPN D indicated she received report in the morning before coming onto the floor and nothing was said about R1 and her ears. LPN D indicated she read through R1's nurse notes from 1/6/23 and noticed R1 was already bleeding then, and her MD was never notified, and no RN assessment was completed. LPN D indicated she called R1's MD and got an order for her to go to ER right away because, I knew she was on Warfarin. I removed the 4x4 to see what was going on and it was still bleeding. I repacked it. I called MD on call. LPN D indicated she reported immediately to DON B because she was the RN on call. On 5/11/23 at 12:02 PM during an interview RN C indicated she was aware R1 was on an anticoagulant. RN C indicated she was also aware R1's ears were bleeding after RN C used a q tip to clean out R1's ears. RN C indicated she did not complete an RN assessment that included the source of the blood, the amount of the blood, the color of the blood, vital signs, and pain level of R1' pain. RN C indicated she placed a cotton ball in R1's ears. RN C indicated she did not recall if R1 had asked her to stop due to pain in her ear. RN C stated, I did not call R1's Medical Doctor to consult with him after the incident and I should have. On 5/10/23 at 12:06 PM CNA F indicated on 1/6/23 before lunch she saw RN going in to R1's room with q tips to flush ears. She saw R1 coming back from lunch and her ears were bleeding. CNA F indicated R1 was on coumadin at that time and was at a higher risk for uncontrolled bleeding. CNA F indicated RN C probably should have reported the bleeding to R1's MD right away especially with the blood thinner. CNA F indicated she observed RN C carrying blood-stained washcloths from R1's room after lunch. CNA F indicated the next day she found R1 in a pool of blood and it was a mess. CNA F got LPN D right away and there was 4x4 gauze packed in R1's ears that the night shift nurse must have put in there. When LPN D pulled the packing out of R1's ear there was a big clot and blood everywhere. CNA F indicated R1 reported that she had told RN C to stop digging in her ears, but she wouldn't stop. CNA F stated, They didn't say anything about it to us in report that morning. I walked in and was in shock. RN H knew about it because the nurse put packing in her ears. On 5/10/23 at 1:00 PM during an interview R1 stated, I was using drops for 5 days and 5th day they were supposed to flush them. RN C took a Q-tip and dug and dug and dug. I told her to stop, and she said we must get that out of there. She kept at it. It bled for a long time and a lot after that. She was only supposed to flush it and not stick anything in there. I don't know if she contacted my doctor. The other nurse came in and put stuff in there. I am on coumadin. They had to change my pillowcase throughout the night because of it. They are supposed to call my doctor if I have bleeding anywhere. I don't let her near me to do anything like that again, but I do take medications from her. On 5/10/23 at 1:27 PM DON B (Director of Nursing) indicated RN C should have performed an RN assessment which included R1's pain level, amount of blood, description of blood, and maybe vital signs. DON B indicated RN C should have updated R1's MD on the incident after she became aware of the blood, especially since she is receiving anticoagulant therapy. DON B indicated she did not update R1's MD and did not perform an RN assessment on R1 when she was made aware of the injury by R1, CNA E, and CNA F on 1/6/23. DON B indicated RN H from the night shift should have performed an RN assessment on R1 when she packed the ears with 4x4 gauze but didn't and she should have completed an RN assessment also with information regarding the blood like what color, how much, and where it was coming from. DON B indicated RN C and RN H should have notified R1's MD when she was aware of her bleeding.