State Findings:
Based on observations, record reviews, interviews and review of the facility’s policies, the facility failed to follow the Physicians’ Orders for two of 20 residents sampled, Resident (R) #145 and R#198. The facility did not consult the Gastrointestinal (GI) physician before administering [MEDICATION(S)], an anticoagulant medication to R#145. Further, the facility did not administer the correct amount of oxygen to R#198.
Review of the hospital Discharge Summary for R#145 dated 4/21/21, documented . Upper GI
(gastrointestinal) bleed to [CONDITION(S)] and gastritis -[MEDICATION(S)] (an anticoagulant medication) discontinued -restart when cleared by GI at a reduced dose of 2-1/2 (two and a half) mg (milligram) twice daily . Discharge Instructions . [MEDICATION(S)] ([MEDICATION(S)]) 2.5 mg tablet, take 1 (one) tablet by mouth 2 (two) times daily. Begin when cleared by GI
Review of R#145’s Admission Minimum Data Set (MDS) dated [DATE] indicated the resident received an anticoagulant medication six of the seven-day observation period.
Interview with the Assistant Director of Nursing (ADON) on 11/19/21 at 11:28 a.m. she stated she could not find evidence the GI Physician was consulted before the facility placed the resident on the anticoagulant ([MEDICATION(S)]).
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