Crown Park Rehabilitation And Nursing Center

brain), drowsiness and with acute/subacute left middle cerebral artery (supplies blood to large portion of the brain) infarct.

The resident was outside the window for administration of thrombolytic therapy (treatment that dissolves blood clots).

The resident had a mechanical heart valve was on warfarin but with the acute stroke and was at high risk of hemorrhage.

The resident most likely had a stroke as evidenced by subtherapeutic (blood level below desired treatment range) International Normalized Ratio.

During an interview on 08/19/2025 at 12:18 PM, Assistant Director of Nursing #3 stated nursing staff filled out the laboratory requisition prior to the lab coming on Tuesdays and Thursdays.

Prothrombin Time/International Normalized Ratios were typically drawn on Tuesdays. If a resident's lab work was missed, they expected the medical provider to be notified immediately and follow the medical provider's order.

Assistant Director of Nursing #3 confirmed Resident #2's record documented orders for weekly Prothrombin Time/International Normalized Ratio's.

The resident had labs drawn on 10/22/2024; however, those labs did not include the Prothrombin Time/International Normalized Ratio and Assistant Director of Nursing #3 was not sure of the reason.

They stated the medical provider should have been notified on 10/22/2024 the lab was missed.

During an interview on 08/19/2025 at 12:55 PM, Physician Assistant #4 stated they became aware of a resident's diagnoses upon admission by reviewing the hospital paperwork or the diagnoses entered by the admission nurse.

Warfarin was a blood thinner and used for blood clots or atrial fibrillation and was monitored by blood work. If a resident's Prothrombin Time/International Normalized Ratio was missed, they expected to be notified and they would either order labs to be done the next day or the next scheduled lab day.

For a resident with diagnoses of both atrial fibrillation and a mechanical heart valve replacement, they expected the International Normalized Ratio to be maintained between 2.5-3.5.

They were not sure of the reason Resident #2's diagnosis of mechanical heart valve was not in their progress notes or in the resident record.

They stated if they knew the resident had a mechanical heart valve, they might have considered increasing the warfarin dose on 10/09/2024, provided the residents condition was relatively stable.

However, they would have weighed the risks if the resident was a high fall risk.

Physician Assistant #4 did not recall being notified on 10/22/2024 of the resident's missed International Normalized Ratio and expected to be notified.

During an interview on 09/04/2025 at 12:54 PM, the Medical Director stated they became aware of a resident's diagnoses by reviewing the diagnoses sheet which was entered by nursing and by reviewing hospital records.

For a resident with atrial fibrillation and a mechanical heart valve, they would want to see the International Normalized Ratio around 2.5-3. If they did not document the resident had a mechanical heart valve in their 09/19/2024 History and Physical, they probably were not aware of the diagnosis, as it was their consistent practice to enter all diagnoses in which they were aware.

The diagnosis should have been on the resident's diagnoses sheet and in the care plan. On 10/09/2024, when the resident's International Normalized Ratio was 1.9, they may have increased the resident's warfarin depending on previous trends of International Normalized Ratio's.

When the resident's International Normalized Ratio was not drawn on 10/22/2024, they should have been notified in order to determine the next steps to be implemented. On 10/25/2024, when the resident was sent to the hospital, the lack of timely International Normalized Ratio monitoring and failure to maintain the resident's International Normalized Ratio in the recommended range for a mechanical heart valve could have contributed to the resident's stroke. 10 NYCRR 415.12

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