The resident, identified as R109, was admitted June 14 with atrial fibrillation, deep vein thrombosis and Factor V Leiden heterozygous mutation — an inherited disorder that causes abnormal blood clots in legs or lungs. The patient required warfarin therapy to prevent potentially fatal clots, with a target INR range of 2.0 to 3.0.
But the facility struggled repeatedly to reach that therapeutic window. On June 15, the patient's INR measured just 1.5. Three days later, it had dropped to 1.2. By June 21 — seven days into treatment — the INR remained dangerously low at 1.3.
Medical guidelines specify that warfarin should achieve therapeutic levels within five to seven days. When INR levels fall below 1.5, protocols call for one-time dose increases of 1.5 to 2 times the daily maintenance dose, with maintenance increases of 10 to 20 percent.
The facility's dosing adjustments fell short of these standards. On June 19, staff increased the weekly warfarin dose by just 10 percent. Two days later, facing an INR of 1.3, they increased it by 14.3 percent. The patient's blood remained insufficiently thinned.
By June 25, after 11 days of treatment, the INR had crept up only to 1.7 — still below the 2.0 minimum. The next day, R109 was hospitalized for shortness of breath. Hospital staff administered Lovenox, a fast-acting blood thinner, because the patient's INR remained below therapeutic levels upon admission.
The pattern continued after R109 returned to the nursing home June 30. On July 2, the INR measured 1.2 again. Staff ordered additional warfarin doses that didn't follow standard protocols for one-time increases. On July 9 — nine days after readmission — the INR was 1.4. Three days later, it had actually decreased to 1.2.
The nurse practitioner managing the case acknowledged the prolonged timeline. During a July 15 interview, E38 told inspectors he had reviewed hospital records and decided against using Lovenox to bridge the patient to therapeutic levels, despite conflicting documentation about bridging recommendations. "I am following the INR and am increasing the dosage with each INR result," he said.
By July 16 — 16 days after the patient's return from the hospital — the INR had only reached 1.5. At that point, staff made a dramatic dosing change, increasing the weekly warfarin from 35 mg to 50 mg, a jump of 42.8 percent.
The attending physician confirmed the delays were problematic. During a July 18 phone interview, E39 stated the INR goal was 2-3 and acknowledged: "It has taken too long."
At the time inspectors completed their survey, the facility still couldn't provide evidence that R109 had achieved therapeutic anticoagulation levels.
The facility also failed two other patients in basic mobility and continence care. R128, a stroke patient with intact cognition, told inspectors on July 9: "I stay in bed and they don't get me up." Despite a physician's order requiring the patient to be out of bed for a minimum of two hours daily, inspectors observed R128 lying in bed repeatedly over three days.
A certified nursing assistant confirmed on July 12 that R128 hadn't gotten out of bed the previous day and hadn't refused. "We did not ask if he wanted to get up," the CNA explained. "He usually tells us that he wants to be up. We did not ask, so he did not refuse." No documentation existed of any refusals by R128.
Two other residents experienced continence problems that staff failed to address properly. R123 was admitted in February as continent of bowel and bladder but became increasingly incontinent over the following months. By July, the patient was incontinent 29 times out of 33 opportunities recorded by staff.
A therapy assistant confirmed R123 could safely use a urinal and bedside commode, but staff weren't providing either. A CNA working with R123 said she didn't offer a urinal or commode to the patient. The facility only began offering a urinal trial after inspectors raised the issue July 15.
R143 showed similar patterns, with incontinence rates climbing from 59 out of 101 opportunities in April to 83 out of 126 in May. Staff completed a voiding diary in early July but failed to implement any plan to restore continence.
The facility's respiratory care also raised safety concerns. R47, a traumatic brain injury patient with a tracheostomy since 2016, had emergency equipment at bedside that didn't match the current tracheostomy size. Emergency orders called for keeping "the same size trach" and "next size smaller trach" at bedside, but staff had size 6 and size 4 replacement tubes when the patient actually wore a size 4.
One registered nurse admitted she was "unsure of R47's trach size prior to today." Two agency nurses couldn't properly explain emergency procedures for tracheostomy patients. One said she would "call the supervisor for help" rather than knowing the protocol herself.
The nurse practitioner overseeing R47's care confirmed the facility lacked proper emergency equipment. "The facility does not have the proper equipment at this time to accommodate a smaller size as the emergency order states," the NP told inspectors.
Another respiratory patient, R121, had oxygen tubing that wasn't labeled with date and initials despite physician orders requiring weekly changes and labeling. A licensed practical nurse confirmed the tubing lacked proper identification.
These violations occurred at a 120-bed facility that provides post-acute and long-term care. The inspection findings were presented to facility leadership including the nursing home administrator, director of nursing, and quality assurance coordinator during an exit conference July 18.
The warfarin management failure represents a particularly serious lapse given R109's high-risk profile. Factor V Leiden mutation affects up to 5 percent of the population and significantly increases clotting risk. Combined with atrial fibrillation and a history of deep vein thrombosis, the patient faced substantial danger from inadequately thinned blood.
The month-long struggle to achieve therapeutic anticoagulation, punctuated by a hospitalization, illustrates how medication management failures can directly impact patient outcomes in vulnerable populations.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ocean Grove Post Acute from 2024-07-18 including all violations, facility responses, and corrective action plans.