Resident #39, who has non-Alzheimer's dementia and schizoaffective disorder, receives 625 milligrams of Depakote three times daily. The anticonvulsant medication requires regular blood monitoring because toxic levels can cause liver damage, blood disorders, and other serious complications.
On February 11, the facility's pharmacy consultant reviewed the resident's chart and found no recent blood levels for the medication. The consultant's note stated they were "unable to locate a recent serum level in the chart" and recommended testing "2 weeks after start then every 6 months thereafter."
The next day, a nurse practitioner responded to the pharmacy recommendation with "Agree Will do" and ordered the blood test for February 13.
The test was never drawn.
Federal inspectors found no evidence the facility collected the blood sample or that medical staff followed up on why the test wasn't completed. The resident continued receiving the high-dose medication without any monitoring of potentially toxic blood levels.
When inspectors interviewed the nurse practitioner on March 19, they admitted ordering the test but said they "wait for the Registered Nurse to inform them of the laboratory test results." The nurse practitioner said they were never notified whether the test was completed or why it wasn't obtained.
The facility's own care plan for the resident specifically requires monitoring laboratory results for drug levels. The care plan was last reviewed on March 7, more than three weeks after the missed blood test.
Medical Director acknowledged the breakdown during the inspection. When interviewed, the Medical Director stated "the Nurse Practitioner should have followed up timely when they had not received the laboratory results."
The Director of Nursing told inspectors that laboratories should communicate with nurses if samples aren't collected and that "a follow up should have been done for laboratory requests that were not completed."
Depakote monitoring is considered essential medical care. The medication can accumulate to dangerous levels in elderly patients, particularly those with kidney or liver problems. Regular blood tests allow doctors to adjust doses before toxic effects develop.
The resident has been on Depakote since January 2023, with the current high-dose order renewed in February 2025. Federal records show the resident has moderately impaired cognition and receives both anticonvulsive and antipsychotic medications.
New Riverdale's own policies require physicians to "address laboratory and other diagnostic test results in a timely manner based on the resident's condition and the clinical significance of the results." The policies also state that staff will "process test requisitions and arrange for tests."
The facility's drug regimen review policy requires attending physicians to respond to pharmacy consultant recommendations within 30 days and "act upon the Drug Regimen Review Findings/recommendation in a timely manner."
Federal inspectors cited the facility for failing to ensure services meet professional standards and for not properly addressing irregularities identified during drug regimen reviews. Both violations were classified as having minimal harm or potential for actual harm.
The inspection occurred more than five weeks after the missed blood test was originally scheduled. Records show no evidence the test was ever completed or that the resident's medication was adjusted based on blood levels.
This case represents a breakdown in the facility's laboratory monitoring system that could have serious consequences for residents requiring careful medication management. The resident continues to receive high doses of a potentially dangerous medication without the blood work needed to ensure safe levels.
The pharmacy consultant's warning went unheeded for over a month, despite multiple staff members acknowledging the importance of the test and agreeing to complete it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for New Riverdale Rehab and Nursing from 2025-03-19 including all violations, facility responses, and corrective action plans.
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