Norwich Rehabilitation & Nursing Center
September 12, 2017 Complaint Survey

Standard Health Citations

FF10 483.30(b)(1)-(3):PHYSICIAN VISITS - REVIEW CARE/NOTES/ORDERS

REGULATION: (b) Physician Visits The physician must-- (1) Review the resident?s total program of care, including medications and treatments, at each visit required by paragraph (c) of this section; (2) Write, sign, and date progress notes at each visit; and (3) Sign and date all orders with the exception of influenza and pneumococcal vaccines, which may be administered per physician-approved facility policy after an assessment for contraindications.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 12, 2017
Corrected date: November 1, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the abbreviated survey (NY 378), it was determined the facility did not ensure the physician reviewed each resident's total program of care, including medications and treatments, for 2 of 4 residents (Residents #1 and 2) reviewed for anticoagulation (blood thinner medication) therapy. Specifically, the facility did not ensure the physicians had an effective monitoring system in place to ensure follow up on routine (PT/INR) testing was done. Findings include: 1) Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was intact and she required extensive assistance with most activities of daily living (ADLs) and received anticoagulation medication daily. The comprehensive care plan (CCP) dated 8/3/2017 did not identify the resident was on a anticoagulation medication and was at risk for complications related to the medication. The physician history and physical dated 7/21/2017 documented the resident had A-fib and the [MEDICATION NAME] would be increased to 5 milligrams daily with the PT/INR rechecked in 3-4 days. A physician order dated 7/21/2017 documented [MEDICATION NAME] 5 mg daily and recheck the PT/INR in 3-4 days. A laboratory form documented the resident's PT/INR was drawn on 7/25/2017 at 2:48 PM and the INR results were 1.90 (therapeutic range 2.00 - 3.00). There were initials documented at the bottom of the form with the date 7/26. A [MEDICATION NAME] flow sheet documented the resident had a PT/INR on 7/21/2017 and the next draw was due on 7/25/2017. There was no further documentation on the flow sheet after 7/25/2017. The 7/2017 Medication Administration Record [REDACTED]INR. The 5 mg of [MEDICATION NAME] continued to be administered after 7/25/2017 with no documented evidence the PT/INR results were reviewed or followed up on. physician progress notes [REDACTED]. The 8/2017 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. A nursing progress note dated 8/23/2017 at 8:00 PM documented the resident and her family member were concerned regarding bruising on her arms and abdomen. A chart review was completed and it identified the resident had not had any recent PT/INR testing done. Physician was called and a new order was placed to obtain a PT/INR. A nursing progress note dated 8/23/2017 at 11:10 PM documented the lab called with a critical INR level of 14.6 (therapeutic range 2.00 - 3.00), Hemoglobin (Hgb) level of 7.0 (normal range 12.2-15.5) and a Hematocrit (Hct) of 23.0 (normal range 37.0-47.0). The resident was transferred to the emergency department. A hospital discharge summary dated 8/24/2017 documented the resident was admitted for observation as she had a critical INR and Hgb & Hct level, she received vitamin K ([MEDICATION NAME] reversal agent) and a blood transfusion. During an interview with the nurse practitioner (NP) on 8/31/2017 at 12:15 PM he stated he would either get called with the PT/INR results or would review them when in the facility. He stated he would ask what the PT/INR level was as well as the current dose of [MEDICATION NAME] and would change the order for [MEDICATION NAME] accordingly and order a repeat PT/INR. Sometimes he was given a laboratory report himself. Othertimes, the physician would be given the report and the physician would initial that he had gone over the results and provided orders over the phone. He stated the facility did not have a good process for monitoring to ensure all PT/INR results were addressed as information was scattered. Resident #1's INR got missed as there was no nurse manager on the unit who reviewed the [MEDICATION NAME] and PT/INR orders. He stated they depended on the nursing staff to ensure orders were in place and follow up was addressed and done. He stated the facility needed to develop a [MEDICATION NAME] book and not the [MEDICATION NAME] flow sheets placed with the MARs as there were new nurses on the carts all the time and the forms needed to be easily accessible for the NP and physicians. 2) Resident #2 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The 8/25/2017 Minimum Data Set (MDS) assessment documented the resident's cognition was moderately impaired, he required extensive assistance for most activities of daily living (ADLs) and received an anticoagulation medication daily. The comprehensive care plan (CCP) dated 8/24/2017 did not identify the resident was on anticoagulation medication and was at risk for complications related to the medication. A physician order dated 8/11/2017 documented [MEDICATION NAME] 3 milligrams (mg) daily for 5 days a week and alternate with 7.5 mg twice a week and obtain a PT/INR on 8/14/2017. A physician history and physical dated 8/15/2017 documented the resident had A-fib and they would continue to monitor his INR. A laboratory report dated 8/15/2017 documented the resident's INR results were drawn on 8/15/2017 at 6:20 AM and the results were 1.32 (therapeutic range 2.00 - 3.00) The report documented the results were reported to the facility at 9:06 AM. There were initials documented on the bottom of the lab report with no date indicating when the lab had been reviewed. The Medication Administration Record [REDACTED]. The initials in the box were circled on 8/14/2017 and on 8/15/2017. On the back of the MAR indicated [REDACTED]. There was no documented evidence the resident's [MEDICATION NAME] dose was adjusted to meet the therapeutic range or a repeat PT/INR was ordered. A physician progress notes [REDACTED]. During an interview with the physician on 9/8/2017 at 1:54 PM he stated he was either notified by phone or given the laboratory results when in the facility. He stated he would always ask a series of questions when notified of results including the results and current dose. He stated he would verbalize the new orders of [MEDICATION NAME] dose and when to repeat the PT/INR to the nurse. She would write out a telephone order and document the new orders on the lab sheet. He stated prior to the incident with Resident #1 there had not been a [MEDICATION NAME] flow sheet to refer to. He stated he did not know why the resident did not have his PT/INR addressed and that would indicate to him the nurse did not do what she was supposed to do. 10NYCRR 415.15(b)(1)(i)(ii)

Plan of Correction: ApprovedOctober 5, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Immediate Corrective action:
Resident?s # 1 & 2 complete medical record including medications and treatments was reviewed by the Medical Director, the attending physician, Nurse Practitioner and Director of Nurses on 9/12/17 to ensure appropriate care was provided. Resident #1 and #2 care plan and C.N.A care guide was updated to reflect risk for bleeding /bruising and anticoagulant use.

Identification of Other Residents
All other residents on [MEDICATION NAME] were reviewed at this time and if clinically indicated all but Resident #1 involved in incident were transitioned to Xarelto to minimize risk of bleeding/bruising.
Systemic Changes
The Medical Director reviewed his expectations and procedures for effective monitoring and total program of care with the Nurse Practitioner and the Attending Physician. The Medical Staff reviewed and approved the revised policy and procedure for [MEDICATION NAME], along with the [MEDICATION NAME] flow sheet, and the Lab Flow sheet.
The policy and procedure on [MEDICATION NAME] will include both the physician and nurse?s responsibility for monitoring lab results to ensure follow up by the physicians on routine PT/INR testing was done.
Quality Assurance Monitoring
Daily monitoring of each resident on [MEDICATION NAME] including lab work, medical review of results, documentation on MARS and [MEDICATION NAME] flow sheet and Laboratory Tracking Sheet will be completed until 100% compliance is achieved. Results of all monitoring will be reported to the QAPI committee monthly. Once 100% compliance is achieved, the QAPI committee will determine the continued frequency of the audit to ensure ongoing compliance.
Person responsible- DON

FF10 483.24, 483.25(k)(l):PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING

REGULATION: 483.24 Quality of life Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident?s comprehensive assessment and plan of care. 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents? choices, including but not limited to the following: (k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents? goals and preferences. (l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents? goals and preferences.

Scope: Isolated
Severity: Actual harm has occurred
Citation date: September 12, 2017
Corrected date: November 1, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the abbreviated survey (NY 378), it was determined the facility did not ensure care and services were provided to attain or maintain the highest practicable physical well-being for 2 of 4 residents (Residents #1 and 2) reviewed for anticoagulation medications (blood thinner/[MEDICATION NAME]). Specifically, the facility did not have an effective system in place to ensure follow up on [MEDICATION NAME] time/international normalized ratio (PT/INR, measures how thin the blood is) laboratory results for Resident #1 and #2. This resulted in actual harm for Resident #1 as she was hospitalized requiring [MEDICATION NAME] reversal agents and treatment to address blood loss. Findings include: 1) Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was intact and she required extensive assistance with most activities of daily living (ADLs) and received anticoagulation medication daily. The comprehensive care plan (CCP) dated 8/3/2017 did not identify the resident was on a anticoagulation medication and was at risk for complications related to the medication. The physician history and physical dated 7/21/2017 documented the resident had A-fib and the [MEDICATION NAME] would be increased to 5 milligrams daily with the PT/INR rechecked in 3-4 days. A physician order [REDACTED]. A laboratory form documented the resident's PT/INR was drawn on 7/25/2017 at 2:48 PM and the INR results were 1.90 (therapeutic range 2.00 - 3.00). There were initials documented at the bottom of the form with the date 7/26. A [MEDICATION NAME] flow sheet documented the resident had a PT/INR on 7/21/2017 and the next draw was due on 7/25/2017. There was no further documentation on the flow sheet after 7/25/2017. The 7/2017 medication administration record (MAR) documented [MEDICATION NAME] 5 mg starting on 7/22/2017 and there was a line under the date of 7/25/2017 with small print under the line documenting INR. The 5 mg of [MEDICATION NAME] continued to be administered after 7/25/2017 with no documented evidence the PT/INR results were reviewed or followed up on. physician progress notes [REDACTED]. The 8/2017 MAR documented [MEDICATION NAME] 5 mg was administered from 8/1/2017 - 8/23/2017. The MAR did not contain any documentation regarding PT/INR's. A nursing progress note dated 8/14/2017 on the 3:00 PM - 11:00 PM shift documented the physical therapist had reported the resident had a bruise on the resident right upper arm. The resident reported she did not know how she got the bruise and she had denied any abuse. A nursing progress note dated 8/23/2017 at 8:00 PM documented the resident and her family member were concerned regarding bruising on her arms and abdomen. A chart review was completed and it was identified the resident had not had any recent PT/INR testing done. Physician was called and a new order was placed to obtain a PT/INR. A nursing progress note dated 8/23/2017 at 11:10 PM documented the lab called with a critical INR level of 14.6 (therapeutic range 2.00 - 3.00), Hemoglobin (Hgb) level of 7.0 (normal range 12.2-15.5) and a Hematocrit (Hct) of 23.0 (normal range 37.0-47.0). The resident was transferred to the emergency department. A hospital discharge summary dated 8/24/2017 documented the resident was admitted for observation as she had a critical INR and Hgb & Hct level, she received vitamin K ([MEDICATION NAME] reversal agent) and a blood transfusion. During an interview with the Director of Nursing (DON) on 8/31/2017 at 9:55 AM, revealed there was no PT/INR/[MEDICATION NAME] policy prior to the incident and she had since developed one. She stated all other resident's in the facility on [MEDICATION NAME] were reviewed to ensure their PT/INR's were up to date. During an interview with the nurse practitioner (NP) on 8/31/2017 at 12:15 PM he stated he would either get called with the PT/INR results or would review them when in the facility. He stated he would ask what the PT/INR level was as well as the current dose of [MEDICATION NAME] and would change the order for [MEDICATION NAME] accordingly and order a repeat PT/INR. Sometimes he was given a laboratory report himself. Othertimes, the physician would be given the report and the physician would initial that he had gone over the results and provided orders over the phone. He stated the facility did not have a good process for monitoring to ensure all PT/INR results were addressed as information was scattered. Resident #1's INR got missed as there was no nurse manager on the unit who reviewed the [MEDICATION NAME] and PT/INR orders. He stated they depended on the nursing staff to ensure orders were in place and follow up was addressed and done. He stated the facility needed to develop a [MEDICATION NAME] book and not the [MEDICATION NAME] flow sheets placed with the MARs as there were new nurses on the carts all the time and the forms needed to be easily accessible for the NP and physicians. During an interview with licensed practical nurse (LPN) #2 on 8/31/2017 at 1:28 PM she stated she would know a resident had a PT/INR due by reviewing the [MEDICATION NAME] Flow Sheet and the MAR. She stated the resident's on [MEDICATION NAME] had a flow sheet placed in with their MARs, which would identify when the next INR was due. The medication nurse would review it daily when passing medications. She stated when an INR was due it was highlighted in the MAR with the [MEDICATION NAME] order and that way the medication nurse would know she needed to review the PT/INR results and question the dose. She stated if she received a lab she would either call the physician with the results or hand them to him if he was in the facility at the time. During an interview with LPN #3 on 8/31/2017 at 1:45 PM she stated she would know a PT/INR was due as there would be a date in the MAR and she would look to make sure it was drawn. If no block in MAR and no recent INR by Wednesday, as that was when they were done, she would notify the supervisor. She stated she did not review laboratory reports as that was the responsibility of the Nursing Supervisor. She stated if she was handed a laboratory report she would place it in the chart for the physician to review or she may call him if the results were out of range. During an interview with the registered nurse (RN) #4 Nursing Supervisor on 8/31/2017 at 2:10 PM she stated there would be a block on the MAR indicating when the INR was due and the [MEDICATION NAME] should not be given after that date in the MAR as a new order would be written. The [MEDICATION NAME] flow sheet should be reviewed daily by the medication nurse and if they noticed it was not filled in they should notify the Nursing Supervisor. She stated it was the responsibility of the nursing supervisor to call the physician with the laboratory results and document right on the report that the physician was notified and what changes were made if any. During an interview with LPN #6 on 8/31/2017 at 3:50 PM she stated in the MAR a date with the [MEDICATION NAME] order would state when the PT/INR was due. If no date she would not give the [MEDICATION NAME] and she would not administer the [MEDICATION NAME] after the INR due date was written on the MAR. She would also review the [MEDICATION NAME] flow sheet as that would contain all the needed information. During an interview with the physical therapist #9 on 9/1/2017 at 8:30 AM she stated she had noticed last month the resident had bruises on both arms and she had reported to the nursing staff on the unit. She stated the resident told her she was not sure how she got the bruise, whether she had bumped it against something or if it was from the blood pressure cuff. During an interview with LPN #10 on 9/1/2017 at 8:40 AM she stated the date of an INR would be highlighted in the MAR so the medication nurse would know the labs needed to be addressed as PT/INRs were done weekly. She stated the medication nurse should have noticed the resident's [MEDICATION NAME] orders in the MAR did not have a date and they should have questioned it and notified the MD that a recent PT/INR had not been done. She stated she had noticed a problem recently with residents not getting labs done. She thought it was due to a lack of training as they had several new nurses who were not aware of the process. During an interview with LPN #12 on 9/1/2017 at 9:20 AM she stated she did recall a physical therapist had reported to her about a bruise and she passed that to the oncoming shift and told them they would have to do some sort of incident about it. During an interview with LPN #13 on 9/1/2017 at 9:55 AM she stated she worked for an agency and had questioned before what their policy was regarding PT/INRs. She stated she was told that if a resident needed one it would be documented in the MAR. If she noticed a date in the MAR for a PT/INR she would notify the supervisor to follow up. She stated PT/INRs often were not her priority as she was responsible for two medication carts during her shift and there was not much time for anything else other than passing medications. During a subsequent interview with the DON on 9/1/2017 at 12:20 PM she stated an accident and incident report was initiated for all injuries of unknown origin including bruises. If a resident had an unexplained bruise she would review their medications and if on a anticoagulant she would review their laboratory values. She stated she was not aware the resident had a bruise on 8/14/2017 and had she known they may have identified the PT/INR error sooner. 2) Resident #2 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The 8/25/2017 Minimum Data Set (MDS) assessment documented the resident's cognition was moderately impaired, he required extensive assistance for most activities of daily living (ADLs) and received anticoagulation medication daily. The comprehensive care plan (CCP) dated 8/24/2017 did not identify the resident was on anticoagulation medication and was at risk for complications related to the medication. A physician order [REDACTED]. A physician history and physical dated 8/15/2017 documented the resident had A-fib and they would continue to monitor his INR. A laboratory report dated 8/15/2017 documented the resident's INR results were drawn on 8/15/2017 at 6:20 AM and the results were 1.32 (therapeutic range 2.00 - 3.00) The report documented the results were reported to the facility at 9:06 AM. There were initials documented on the bottom of the lab report with no date indicating when the lab had been reviewed. The medication administration record (MAR) documented the resident had an PT/INR due on 8/14/2017. The initials in the box were circled on 8/14/2017 and on 8/15/2017. On the back of the MAR it was documented by LPN #12 8/15/2017 no INR f/u at 1600. There was no documented evidence the resident's [MEDICATION NAME] dose was adjusted to meet the therapeutic range or a repeat PT/INR was ordered. A physician progress notes [REDACTED]. During an interview with LPN #12 on 9/1/2017 at 9:20 AM initially stated she was not sure regarding the process of ensuring PT/INRs were done and addressed as she did not work there very often. She stated if there was a date of an INR with a [MEDICATION NAME] order in the MAR she would go look to see what the results were before giving the [MEDICATION NAME]. If the INR was not within normal limits she would notify the physician. She stated she would not document on the lab sheet to indicate it was addressed. She would document a telephone order and a nursing progress note. She stated she could not recall seeing a date of the resident's PT/INR or if she had notified anyone and was sure she had. She stated if she put her initials on the MAR with a circle around them it indicated the medication was not given. During an interview with the physician on 9/8/2017 at 1:54 PM he stated he was either notified by phone or given the laboratory results when in the facility. He stated he would always ask a series of questions when notified of results including the results and current dose. He stated he would verbalize the new orders of [MEDICATION NAME] dose and when to repeat the PT/INR to the nurse. She would write out a telephone order and document the new orders on the lab sheet. He stated prior to the incident with Resident #1 there had not been a [MEDICATION NAME] flow sheet to refer to. He stated he did not know why the resident did not have his PT/INR addressed and that would indicate to him the nurse did not do what she was supposed to do. 10NYCRR 415.12

Plan of Correction: ApprovedOctober 5, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Immediate Corrective Action:
Medical Record review for residents 1 & 2 who are on [MEDICATION NAME] was completed by the Medical Staff and the DON on 9/12/17 to ensure routine monitoring of PT/INR was completed, indications were appropriate. Resident #1 and #2 both care plans and C.N.A care guides were reviewed to ensure current anticoagulation monitoring is current and documented.
Daily monitoring of lab results and subsequent orders on all residents including residents # 1 and 2 on [MEDICATION NAME] was implemented.
Identification of Other Residents:
All residents on [MEDICATION NAME] were assessed for signs/symptoms of hyper coagulant state and or Hypo coagulant state, bleeding/bruising with no additional signs of bleeding or bruising identified.
All resident care plans and C.N.A care guides were reviewed and revised to ensure staff awareness of bleeding risks and individualized plan of care to prevent complications.
Medical Record review for all residents of [MEDICATION NAME] was completed by the Medical Staff and the DON on 9/12/17 to ensure routine monitoring of PT/INR was completed, indications were appropriate.
Systemic Changes:
The Facility policy and procedures pertaining to investigations was reviewed and revised to ensure completed and thorough investigations are conducted when indicated to ensure timely intervention.
All staff will be educated on revised policy & procedure. The Medical Team met and concurred that going forward the anticoagulant of choice is going to be Xarelto unless contraindicated.
A system to ensure lab results (PT/INRs) are appropriately communicated to the Medical Staff was developed and implemented. All licensed nurses will be educated on new lab process.
All direct care staff were educated on recognizing the symptoms of hypo coagulant state including bleeding/bruising, and to report findings to charge nurse for follow up and to be reported on the 24 hour AM report for additional review and follow up.
A [MEDICATION NAME] flow sheet was developed and implemented to ensure proper monitoring and follow up of [MEDICATION NAME] and PT/INR. New flow sheet was added to the policy and all licensed nurses will be educated on use of the flow sheet and updated [MEDICATION NAME] policy.
In addition to the [MEDICATION NAME] Flow Sheets the process for documenting [MEDICATION NAME] and PT/INR on the MARS now includes a STOP Check PT/INR on the date the repeat lab is due to be reported. A new order for the next [MEDICATION NAME] dose will be required. The [MEDICATION NAME] Policy has been revised to include the ammendment to the MAR. All RNs and LPNs will be educated on the revision to the MAR process and revised [MEDICATION NAME] Policy.
Quality Assurance Monitoring:
A daily audit comparing the 24 hour report, Physician communication book, weekly LPN skin checks on designated bath days will be conducted to identify any unreported potential Accidents or Incidents. This audit will be done for 1 month with results reported to the QAPI Committee, and repeated weekly thereafter until 100% compliance is achieved. Once 100% compliance is achieved, the QAPI committee will determine the continued frequency of the audit to ensure ongoing compliance.
In addition to the [MEDICATION NAME] Flow Sheets the process for documenting [MEDICATION NAME] dose and the next PT/INR on the MARS has been revised to include a designated STOP date and alert to check PT/INR. When the new order is obtained a new entry will be made into the MAR and will include the next STOP date. All RNs and LPNs will be educated on the revised process.
A second audit of all residents on [MEDICATION NAME] will be conducted by auditing the [MEDICATION NAME] flow sheets weekly to ensure appropriate follow up of lab results and orders. This audit will be completed weekly for four weeks or until 100 % compliance is achieved. Once 100% compliance is achieved, the QAPI committee will determine the continued frequency of the audit to ensure ongoing compliance.
Person Responsible-DON