Divine Providence Community Home

Review of the current, undated Xaralto (anti-coagulant) patient safety information, located at: https://www.xarelto-us.com/what-is-xarelto/?utm_source=bing&utm_medium=cpc&utm_campaign=EG-DTCB-BR-NA-Xarelto-JJ-Priority/Top-Phrase-NA&utm_content=Core+Branded-TXT-National-NA-1-PH&utm_term=xarelto&gclid=8931e1615f0a13ed37da8886d53418dc&gclsrc=3p.ds&msclkid=8931e1615f0a13ed37da8886d53418dc, identified Xarelto was a blood thinner that treats and helps prevent blood clots that are related to certain conditions involving the heart and blood vessels.

Anticoagulants lower your blood's ability to clot by stopping specific proteins and enzymes, also known as clotting factors, from doing their job to help blood clots form.

Side effects of Xarelto included increased risk of bleeding.

Patients were likely to bruise more easily, and it may take longer for bleeding to stop which can be serious and may lead to death.

Patients were to notify a physician or receive medical attention if a patient developed signs or symptoms of bleeding such as:Unexpected bleeding or bleeding that lasts a long time, such as:Nosebleeds that happen often.Unusual bleeding from gums.Menstrual bleeding that is heavier than normal, or vaginal bleeding.Bleeding that is severe or you cannot control.Red, pink, or brown urine.Bright red or black stools (looks like tar).Cough up blood or blood clots.Vomit blood or your vomit looks like coffee grounds.Headaches, feeling dizzy or weak.Pain, swelling, or new drainage at wound sites.Left upper belly (abdominal) pain, pain below the left rib cage or at the tip of your left shoulder or diffuse abdominal discomfort (these may be symptoms of the rupture of the spleen).

Review of the National Library of Medicine (NLM) article located at: https://pmc.ncbi.nlm.nih.gov/articles/PMC12284669/, To anti-coagulate or not to anti-coagulate-that is the question in patients with fall risks, identified falls were associated with an increased risk of traumatic bleeding events and death.

Another NLM article located at: https://pmc.ncbi.nlm.nih.gov/articles/PMC11242576/, Traumatic Brain Injury in Patients under Anticoagulant Therapy: Review of Management in Emergency Department identified the National Institute for Health Care Excellence (NICE) suggested considering conducting a head CT scan for people who have sustained a traumatic brain injury (TBI) [ex: hitting their head from a fall] and have no other indications for a head CT scan, except being on anticoagulant therapy.

There was no policy related to anti-coagulation monitoring provided by the end of survey.

245599 04/15/2026

Divine Providence Community Home 700 Third Avenue Northwest Sleepy Eye, MN 56085

Review of 3/10/26, interdisciplinary team (IDT) meeting note identified the IDT did a review of R4's 2/22/26 fall on 2/24/26 with a new identified intervention of having R4 in the living room area for supervision as much as able, and to continue with her therapy treatments. R4's current, undated care plan, identified R4 required 2 staff to assist with transfers and toileting. R4 did not understand instructions and was not able express her needs. R4 had a wander guard on her wheelchair. R4 could not safely transfer without assistance and had a bed and chair sensor alarm in place that connected to and turned on the call light and/or pager.

The care plan lacked identification that R4 should remain in the dining room until staff were around the living room area and to ensure staff were in the dining room area while R4 was there or that R4 should be in the living room area as much as possible for supervision.

Interview and care plan review on 4/15/26 at 2:17 p.m., with registered nurse (RN)-A identified R4 had been admitted to the facility for failure to thrive and dementia. R4 had 2 falls since admission in February 2026. RN-A identified the only intervention on her care plan was to have a bed and chair alarm. RN-A confirmed the interventions that had been identified on the 2/22/26, fall report had not been added to the care plan following R4's second fall that resulted in a fractured of her pelvis. RN-A identified when a fall occurred, that the charge nurse would complete a fall report and that person was to update the care plan with the new interventions.

Then the IDT meets weekly and reviews any falls and would review interventions.

The IDT also should update the care plan if the intervention was changed after review. RN-A stated the care plan should be updated any time care needs change for a resident.

Interview on 4/15/26 at 4:14 p.m., with the administrator identified she would expect that R4's care plan would reflect her current care needs including identified fall interventions.

Any time a new intervention or care need was identified to care for a resident that the care plan would be updated.

Review of undated Fall and Post-Fall Assessment identified that following a fall the nurse would assess the resident and provide necessary medical attention.

The environment would be evaluated for possible causes and necessary action would be taken to correct as needed.

The family and medical doctor would be updated and notified of new interventions.

Interventions would be added to the care plan and communicated to the staff.

245599 04/15/2026

Divine Providence Community Home 700 Third Avenue Northwest Sleepy Eye, MN 56085

Review of April 2017, Pressure Ulcer Assessment policy identified pressure ulcers would be evaluated, measured and characteristics of the wound would be documented weekly to determine worsening or improvement.

245599 04/15/2026

Divine Providence Community Home 700 Third Avenue Northwest Sleepy Eye, MN 56085

Survey findings were discussed, specifically that one resident (R4) who was reviewed for falls failed to have their care plan revised after new interventions were identified to be implemented and would have been identified had the QAPI committee reviewed specifics around IDT review for falls and appropriate oversight would have occurred.

The administrator agreed with that discussion and understood need for documenting the oversight.

Review of the February 2026, Quality Assurance/Assessment and Performance Improvement Plan identified QAPI would make quality improvement decisions based on data analysis with input from residents, families, staff and the community. QAPI was to set goals for performance and measures progress toward those goals.

The committee was to include representatives from all departments including nursing, food and nutrition, laundry, housekeeping, maintenance, health information technology, therapeutic recreation, therapy, business office and administration.

245599 04/15/2026

Divine Providence Community Home 700 Third Avenue Northwest Sleepy Eye, MN 56085

Review of the February 2026, Quality Assurance/Assessment and Performance Improvement Plan identified QAPI would make quality improvement decisions based on data analysis with input from residents, families, staff and the community. QAPI was to set goals for performance and measures progress toward those goals.

The committee was to include representatives from all departments including nursing, food and nutrition, laundry, housekeeping, maintenance, health information technology, therapeutic recreation, therapy, business office and administration.

There was no specific mention to the IP bringing all surveillance data to QAPI for review.

Review of the January 2026, Infection Control Coordinator policy, identified the infection control coordinator was to report information related to compliance to Administrator and Quality Assurance and Assessment Committee.

The IP was to collect, analyze, and investigate data and trends to nursing staff and health practitioners; maintain infection logs for staff and residents; consult on strategies for infection prevention; and implement evidence-based control practices.

Infection logs -summaries of infections.

Review of the January 2026, Staff with Signs and Symptoms of Infectious Disease policy identified staff assessment protocols were to have been established in order for the facility to be notified if a staff member had symptoms of an infectious disease and must stay out of the facility.

The goal was to prevent residents from contracting communicable disease and prevent an outbreak.

Staff exhibiting any of the symptoms below need to call into DPCH and report the symptoms they are having.

The staff member receiving the call were to document the employee's signs and symptoms such as: VomitingDiarrheaGeneralized body achesCoughRunny and or stuffy noseHeadachesChillsFatigueTemperature Sore Throat Once a staff's temperature had been normal for 24 hours without taking fever reducing drugs and other symptoms were absent, the employee was allowed to return to work, depending on the infection (testing may be requested).

There was no indication the policy followed national standards of practice and/ or State guidelines, depending upon the symptoms.

There was also no mention of how the process was to occur or that staff who were taking the call-ins had been appropriately trained per national and state standards for vetting employees in order to safely RTW.

The policy did note staff were to be trained upon hire and annually on signs and symptoms of infectious disease.

245599 04/15/2026

Divine Providence Community Home 700 Third Avenue Northwest Sleepy Eye, MN 56085