Alaska Gardens: Medication Safety Failures Affect 12 Residents - WA
TACOMA, WA - Federal inspectors found widespread medication errors affecting all 12 residents reviewed at Alaska Gardens Health and Rehabilitation during a March inspection, including failures to administer critical blood thinners and insulin that placed residents at risk for adverse health events.
Critical Blood Thinner Oversight
The most serious violation involved a resident with a history of stroke and heart attack who was prescribed dabigatran, a blood-thinning medication essential for preventing dangerous blood clots. Hospital discharge records from December 2024 clearly showed orders for dabigatran 150mg twice daily, yet facility staff failed to transcribe this critical medication into admission orders.
The resident was later transferred to the hospital in January 2025 for neurologic changes. Hospital records confirmed the resident had not received the prescribed blood thinner during their entire stay at the facility from December 16, 2024, to January 30, 2025.
Blood-thinning medications like dabigatran are prescribed specifically to prevent stroke recurrence in patients with cardiovascular conditions. When these medications are discontinued without medical supervision, patients face significantly elevated risks of blood clots forming in the heart or brain vessels, potentially leading to life-threatening strokes or heart attacks.
Insulin Management Failures
Multiple residents with diabetes experienced dangerous delays in insulin administration that could have led to serious complications. One resident's blood glucose reached 290 mg/dL - nearly three times the normal level - yet insulin was administered three hours after the blood sugar reading instead of immediately as medically indicated.
Elevated blood glucose levels above 180 mg/dL require prompt intervention to prevent diabetic ketoacidosis, a potentially fatal condition. Professional diabetes management standards require insulin administration within 15-30 minutes of elevated blood glucose readings to effectively control dangerous sugar spikes.
"Resident 14 blood sugars were poorly controlled and they were supposed to be on insulin but were not when they admitted," a family member told inspectors during the investigation.
Another resident was prescribed medium-dose sliding scale insulin every six hours due to tube feeding, yet staff failed to transcribe or initiate the blood sugar monitoring and insulin orders upon readmission to the facility.
Allergy Protocol Violations
In a particularly concerning case, staff administered Lantus insulin to a resident with a documented allergy to this specific medication. Hospital discharge orders clearly indicated the resident was allergic to Lantus insulin and should receive a different formulation, yet facility records show Lantus was administered on the day of admission.
Drug allergies can trigger severe reactions ranging from skin rashes to life-threatening anaphylaxis. Professional nursing standards require verification of all known allergies before medication administration, and alternative medications must be used when allergies are documented.
Systematic Medication Reconciliation Failures
The inspection revealed the facility consistently failed to conduct proper medication reconciliation - a critical safety process where healthcare providers verify all medications a patient should receive against their medical orders. This fundamental safety step prevents dangerous medication errors and ensures continuity of care during transitions.
Standard medical practice requires comprehensive medication reconciliation within 24 hours of admission, comparing hospital discharge medications with facility admission orders to identify any discrepancies. The facility's own policy required this process, yet records showed it was not performed for any of the reviewed residents.
Delayed Medication Administration
Beyond missing medications entirely, the facility demonstrated chronic problems with timely administration. One resident receiving dialysis treatment missed critical phosphate binder medications that must be taken with meals to be effective. Records showed this resident received the medication more than two hours after meals on 13 separate occasions in February 2025.
"They did not receive their medications on time, and sometimes did not get them," one resident told inspectors about their medication experience.
Professional nursing standards specify that medications must be administered within one hour of the scheduled time to maintain therapeutic effectiveness. Late administration can reduce medication efficacy and potentially compromise patient safety.
Physician Notification Failures
When medications were unavailable or errors occurred, staff consistently failed to notify physicians as required by professional standards and facility policy. One physician told inspectors they were unaware that a resident had missed 10 doses of heart failure medication over a 30-day period.
Proper communication protocols require immediate physician notification when medications cannot be administered as ordered, allowing doctors to provide alternative treatments or adjust dosing schedules to maintain patient safety.
The inspection found the facility's medication error prevention systems were inadequate, with outdated policies and insufficient oversight of nursing staff practices. These systematic failures placed residents at risk for rehospitalization, poorly managed chronic conditions, and potential adverse medical events.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Alaska Gardens Health and Rehabilitation from 2025-03-19 including all violations, facility responses, and corrective action plans.
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