SANTA MONICA, CA - A federal inspection of Ocean Park Healthcare, operating as Santa Monica Conv Ctr I, revealed that staff failed to transcribe and administer a prescribed blood thinner medication for a resident with atrial fibrillation, creating potential risks for stroke and blood clots.
Critical Anticoagulant Medication Omitted During Admission
The April 2025 complaint investigation documented a significant medication management failure involving a resident who was transferred from a general acute care hospital with a diagnosis of atrial fibrillation, a condition characterized by irregular heartbeat that increases the risk of stroke and other cardiovascular complications.
According to inspection records, Resident 1 arrived at the facility on February 14, 2025 with physician transfer orders that included apixaban (Eliquis) 5 milligrams twice daily - a blood thinner essential for preventing dangerous blood clots in patients with atrial fibrillation. However, the medication was never transcribed into the facility's medication administration system and was therefore never given to the resident.
The resident's medical history documented atherosclerotic heart disease, a previous cerebral infarction (stroke), and the presence of a cardiac pacemaker - conditions that underscore the critical importance of maintaining anticoagulation therapy. Despite nursing progress notes from February 14, 2025 stating that "all orders verified with medical doctor, all orders noted and carried out," the anticoagulant medication was completely absent from the facility's records.
Multiple Staff Acknowledge System Failure
The inspection revealed a breakdown in the facility's medication reconciliation process involving multiple staff members. Licensed Vocational Nurse 3, who was responsible for entering medications into the electronic care system, acknowledged the error during the investigation.
"It might be an honest mistake omitting the apixaban/Eliquis from Resident 1's MAR," LVN3 told inspectors, adding that "blood thinners are high-risk medications, there is a potential harm and complications from missing the prescribed doses."
The attending physician confirmed during a telephone interview that he had approved the resident's existing transfer medications, including the anticoagulant. "I do know he was supposed to be on anticoagulant," the physician stated, noting that he had provided telephone orders to facility staff for approval of the transfer medications.
A Registered Nurse supervisor explained that the resident was admitted on a Friday afternoon near the end of the shift. The RN began the basic assessment but endorsed the admission process to the evening charge nurse without completing the medication review. After reviewing the records during the inspection, the RN supervisor acknowledged the omission and stated directly: "It is a deficiency and harm risk for the resident."
Why Anticoagulation Matters for Atrial Fibrillation Patients
Atrial fibrillation causes the heart's upper chambers to beat irregularly, which can allow blood to pool and form clots. When these clots travel to the brain, they can cause ischemic strokes - a leading cause of disability and death. Anticoagulant medications like apixaban work by inhibiting specific clotting factors in the blood, significantly reducing stroke risk in affected patients.
For patients with Resident 1's medical profile - including a prior cerebral infarction, atherosclerotic heart disease, and cardiac pacemaker - consistent anticoagulation therapy is considered essential to prevent recurrent stroke events. Missing even a few doses of these medications can allow blood clot formation to begin, though the risk increases substantially with longer gaps in therapy.
The resident's Minimum Data Set assessment, completed three days after admission, documented moderately impaired cognitive skills for daily decision-making, meaning the individual could not be expected to self-advocate for missing medications. The assessment notably indicated that high-risk drug classes for anticoagulants were "not assessed."
Facility Policy Violated
The inspection cited violations under two federal regulations: F760, concerning medication management, and F842, regarding maintenance of accurate medical records. Both were classified as causing minimal harm or potential for actual harm.
The facility's own Medication Reconciliation Policy, revised in April 2024, specifically outlines the process for verifying medications during transfers from hospitals or other providers. The policy requires comparing hospital discharge medication lists with facility admission orders. Additionally, the facility's Admission Record Audit policy mandates chart audits within 72 hours of admission "to ensure that documentation is complete, accurate, and compliant."
The pharmacy supervisor confirmed that the pharmacy never received an order for apixaban. "Pharmacy does not dispense medications without MD orders," the supervisor explained, indicating the breakdown occurred before orders reached the dispensing stage.
The resident was subsequently transferred to a sister facility within two days of admission, and the inspection did not document any adverse events resulting from the missed medication doses. However, the brief window between doses represents a period of elevated risk for a patient with documented cardiovascular disease and stroke history.
Additional Issues Identified
The inspection also cited the facility for maintaining incomplete and inaccurate medical records. The failure to transcribe the prescribed anticoagulant meant that Resident 1's official facility records did not accurately reflect the medications ordered by the transferring hospital's physicians, creating a documentation gap that contributed to the treatment failure.
The Director of Nursing confirmed during the inspection that the medication "should have been included in Resident 1's MAR and administered according to the physician's order," attributing the omission to "a failure to transcribe and medication reconciliation."
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Santa Monica Conv Ctr I from 2025-04-22 including all violations, facility responses, and corrective action plans.
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