LOS ANGELES, CA - Federal inspectors documented dangerous medication errors at Alexandria Care Center that put residents at risk of potentially fatal bleeding complications from blood thinner overdoses.
Double Doses of Blood Thinner Documented
During a January 31, 2025 inspection, investigators discovered that Resident 10 had two active orders for the same blood thinner medication - rivaroxaban 10mg - with nurses signing off on administering both doses simultaneously between January 20-28, 2025.
The facility's Medication Administration Record showed: - One rivaroxaban order starting May 28, 2024 - A second identical rivaroxaban order starting January 19, 2025 - Both 10mg doses signed as administered by multiple nurses over an 8-day period
The Director of Nursing acknowledged this created life-threatening risks, stating the resident "could potentially receive both doses of rivaroxaban if the medication was available and lead to harm by causing excessive bleeding and possibly death."
Critical Medication Safety System Failures
Rivaroxaban belongs to a class of blood thinners that prevent dangerous clots but carry significant bleeding risks when overdosed. The therapeutic window between effective treatment and dangerous bleeding is narrow, making precise dosing critical for patient safety.
The facility's medication management system failed at multiple levels: - Duplicate orders were not identified when the new prescription was written - Multiple licensed nurses signed off on administering both doses without recognizing the duplication - No safety checks caught the error during the 8-day administration period
Missing Blood Thinner Monitoring
Investigators found additional medication safety violations involving Resident 141, who was prescribed Pradaxa (dabigatran) for atrial fibrillation. Despite facility policies requiring bleeding monitoring for patients on blood thinners, no documentation existed for monitoring side effects between January 1-30, 2025.
The resident's care plan specifically identified bleeding risks, stating the goal was to "monitor for active bleeding." The Director of Nursing confirmed that monitoring for bleeding with Pradaxa use was important to ensure the resident does not have bleeding that was unnoticed, which may harm the resident and require hospitalization.
Psychotropic Medication Violations
Beyond blood thinner errors, inspectors documented inappropriate use of mind-altering medications. Resident 21 was prescribed sertraline (antidepressant) for "depression manifested by sadness" despite assessment scores showing zero symptoms of depression or hopelessness.
Resident 358 received both quetiapine (antipsychotic) for "agitation" and sertraline for "unhappiness" - terms inspectors found too vague for proper monitoring. The facility's own policies require specific, measurable behavioral targets for psychotropic medications.
Widespread Medication Administration Errors
Inspectors observed a 10.35% medication error rate - more than double the 5% federal threshold - during routine medication administration observations. Errors included:
- Resident 257 receiving chewable aspirin instead of the prescribed enteric-coated form, increasing stomach irritation risk - Resident 109 receiving medications 100 minutes late, outside the facility's 60-minute administration window
Insulin Site Rotation Failures
The facility failed to rotate injection sites for three residents receiving insulin, increasing risks of lipodystrophy (abnormal fat distribution) and other injection site complications. Proper site rotation prevents tissue damage and maintains medication absorption effectiveness.
Medical Implications of Blood Thinner Errors
Blood thinners like rivaroxaban work by blocking specific clotting proteins in the blood. When doses are doubled, the anticoagulant effect intensifies dramatically, potentially causing:
- Internal bleeding in the brain, stomach, or other organs - Excessive bleeding from minor injuries that won't stop - Hemorrhagic complications requiring emergency intervention
For patients with conditions like deep vein thrombosis or atrial fibrillation, blood thinners are essential for preventing potentially fatal clots. However, the margin between therapeutic benefit and dangerous bleeding is narrow, requiring precise dosing and careful monitoring.
Industry Standards and Protocols
Federal nursing home regulations require facilities to ensure each resident's drug regimen is free from unnecessary medications and that medications are administered as prescribed. Standard medication safety protocols include:
- Verification of the "five rights" - right patient, medication, dose, time, and route - Identification and discontinuation of duplicate orders - Regular monitoring for medication side effects - Documentation of all medication-related observations
The facility's own policies acknowledged these requirements, stating that "medications are administered in a safe and timely manner, and as prescribed" and that "orders for medications and treatments will be consistent with principles of safe and effective order writing."
Regulatory Response and Oversight
The Centers for Medicare & Medicaid Services cited Alexandria Care Center for multiple violations related to medication management and safety. These violations carry "minimal harm or potential for actual harm" classifications but represent serious systemic failures in resident protection.
The facility is required to develop and implement corrective action plans addressing each identified deficiency. Continued violations could result in financial penalties, increased oversight, or potential loss of Medicare/Medicaid certification.
Federal regulations mandate that nursing homes maintain medication error rates below 5%. Alexandria Care Center's documented 10.35% error rate indicates fundamental problems with staff training, oversight systems, and safety protocols.
The inspection findings highlight ongoing challenges in nursing home medication management, particularly for complex medications like blood thinners that require careful monitoring and precise administration. Residents and families should inquire about facilities' medication safety records and protocols when evaluating care options.
For the complete inspection report and facility response plans, families can contact the California Department of Public Health or access documents through the federal Nursing Home Compare database.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Alexandria Care Center from 2025-01-31 including all violations, facility responses, and corrective action plans.
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