Resident 9 had been prescribed weekly blood tests to check for dangerous side effects from clozapine, a powerful antipsychotic medication used to treat schizophrenia. The drug can destroy infection-fighting blood cells, making regular monitoring critical for patient safety.
The resident also needed weekly tests to measure levels of valproic acid, another psychiatric medication used to treat mood swings. Without proper monitoring, patients can receive toxic doses or ineffective amounts.
Staff documented that Resident 9 refused blood draws on January 31, 2025 and February 3, 2025. The refusals were noted on requisition forms and patient service logs. But no one contacted the physician.
During an April 28 inspection, the Director of Nursing confirmed that doctors were never notified of the refusals. She acknowledged this was a pattern of behavior for Resident 9, who regularly refused to have blood drawn.
"The DON verified Resident 9's doctor was not notified each time Resident 9 refused the blood draws," inspectors wrote.
The resident had been readmitted to Claremont Heights Post Acute in October 2024 with multiple serious conditions. Medical records showed metabolic encephalopathy, which alters brain function and structure. The resident also had schizoaffective disorder, combining symptoms of schizophrenia with mood disorders, and Alzheimer's disease.
A March assessment found Resident 9 was severely impaired in cognitive skills and ability to make daily decisions. The resident required substantial help from staff for basic activities like dressing and moderate assistance for bathing and toileting.
The facility's own policy required staff to notify physicians of changes in a resident's condition "in a timely manner." The policy, last revised in April 2015, specifically stated that care plans should be updated to reflect current resident status.
But Resident 9's care plan contained no interventions to address the pattern of refusing blood tests. The plan also failed to include the ordered blood tests in its interventions section, despite being updated as recently as February 29, 2025.
The Director of Nursing explained why the blood tests were medically necessary. The CBC test was needed because valproic acid "could negatively affect Resident 9's infection fighting blood cells." The valproic acid level test was required "to ensure Resident 9 was getting the right amount of the valproic acid medication."
She acknowledged that "the doctor should be notified of Resident 9's refusals."
The physician had ordered the complete blood count tests every Monday starting December 31, 2024, specifically due to clozapine use. A separate order from March 26, 2025 required valproic acid levels every Wednesday.
Federal inspectors found the facility failed to develop a comprehensive care plan that addressed the resident's specific needs. Without proper interventions for medication refusal behaviors, residents face potential harm from unmonitored psychiatric drugs.
Clozapine carries particular risks. The medication requires regular blood monitoring because it can cause agranulocytosis, a dangerous condition where white blood cell counts drop to life-threatening levels. Patients taking clozapine must have blood drawn weekly for the first six months of treatment.
The inspection was conducted in response to a complaint. Inspectors classified the violations as causing minimal harm or potential for actual harm, affecting some residents at the 590 South Indian Hill Boulevard facility.
Resident 9's case illustrates how communication breakdowns can compromise medication safety for vulnerable nursing home residents with complex psychiatric conditions and cognitive impairments.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Claremont Heights Post Acute from 2025-04-28 including all violations, facility responses, and corrective action plans.