TAUNTON, MA - A heart transplant patient at Regalcare at Taunton required emergency hospitalization after facility staff failed to properly administer his critical immunosuppressant medication for nearly three weeks, according to a state inspection report.
Critical Medication Error Puts Transplant Patient at Risk
The most serious violation documented at Regalcare at Taunton involved a catastrophic medication error that left a heart transplant recipient without his essential anti-rejection medication for 20 days. The resident, who had received a heart transplant in 2021, was prescribed tacrolimus (Prograf) - a life-sustaining immunosuppressant that prevents the body from rejecting transplanted organs.
After returning from a February 2025 hospitalization, the resident should have received tacrolimus twice daily: 2 mg each morning at 9 A.M. and 3 mg each evening at 9 P.M. However, due to an error in the facility's medication ordering system, the prescription was discontinued in error on February 27, 2025, the same day it was entered.
The resident missed a total of 40 doses of this critical medication between February 27 and March 19, 2025. During this period, his tacrolimus blood level dropped to a dangerously low 1.2 ng/ml - far below the target therapeutic range of 4-6 ng/ml required to prevent organ rejection.
Tacrolimus is essential for transplant recipients because it suppresses the immune system's natural tendency to attack foreign tissue. Without adequate levels of this medication, transplant patients face the risk of acute rejection, which can cause permanent damage to the transplanted organ and potentially fatal complications.
Communication Breakdown With Specialist Care Team
The medication error was compounded by significant communication failures between the nursing home and the resident's cardiology team at the hospital. According to the inspection report, the hospital's Cardiology Registered Nurse made multiple attempts to obtain the resident's current medication list and laboratory results but encountered "extensive hurdles" when trying to contact facility staff.
The cardiology nurse attempted to reach the facility on February 27, March 4, March 5, and March 18, 2025, but was unable to connect with appropriate nursing or medical staff. When she finally received the resident's medication list on March 19, she immediately noticed that tacrolimus was missing from the list entirely.
"The Cardiology RN said she placed a call to the facility and spoke with a nurse who reported the medication had been discontinued on 2/27/25," the inspection report states. The cardiology nurse noted that "the Resident had gone a significant amount of time without the anti-rejection medication before she was able to speak with someone at the facility."
This communication breakdown prevented early detection of the medication error. The cardiology team regularly monitors transplant patients and could have identified the missing medication much sooner if they had received timely responses to their requests for information.
Laboratory Monitoring Failures
The facility also failed to properly monitor and communicate critical laboratory results. A tacrolimus level drawn on March 6, 2025, showed the dangerously low result of 1.2 ng/ml, which was reported to the facility on March 11. However, facility staff failed to notify the resident's cardiology team of this critical finding.
The cardiology team only became aware of the abnormal laboratory result eight days later, on March 19, when they finally received the delayed medication list and lab results. By this point, the resident had been without his anti-rejection medication for nearly three weeks.
Standard protocols for transplant patients require immediate notification of abnormal tacrolimus levels to the supervising transplant team, as these results directly impact medication dosing decisions and patient safety. The delay in reporting these critical values represented a serious breakdown in the facility's clinical oversight systems.
Emergency Hospitalization and Treatment
Once the medication error was discovered, the resident's cardiologist immediately recommended emergency hospital admission for rejection surveillance. The hospital's transplant team was concerned about potential organ rejection and the need for intensive monitoring and treatment.
During his week-long hospitalization, the resident underwent comprehensive testing including a transthoracic echocardiogram and blood work to assess for signs of organ rejection. Fortunately, the testing was "reassuring" and the transplant team decided against performing a heart biopsy.
However, the resident required significant medical interventions as a direct result of the medication error, including: - Increased tacrolimus dosing to restore therapeutic levels - Intravenous steroid infusions as empiric anti-rejection therapy - Adjustments to his insulin regimen due to elevated blood sugar from steroid treatment - Weekly laboratory monitoring for two weeks following discharge
The cardiology nurse emphasized the potential severity of the situation, noting that "the medication error could have caused organ transplant rejection, which can be irreversible and could have resulted in a severe outcome."
Administrative and System Failures
The inspection also identified significant administrative oversight failures that contributed to the medication error and delayed its detection. The facility's administration failed to ensure proper systems were in place for medication reconciliation, laboratory result reporting, and communication with consulting providers.
Specifically, the facility failed to complete a required Admission Medication Regimen Review (AMRR) within 72 hours of the resident's return from the hospital. This pharmacy review is designed to catch exactly the type of medication discrepancy that occurred. According to the Regional Pharmacy Manager, "had an AMRR been completed, this discrepancy would have been identified at that time."
The facility's assessment documentation failed to address the use of laboratory services and pharmacy services, including how discrepancies and concerns should be escalated to administration. Additionally, staff had not received in-service education on medication reconciliation, provider notification of abnormal lab results, or communication with consulting providers before the error occurred.
Additional Issues Identified
The inspection revealed other concerning patterns related to the facility's clinical oversight:
- The facility's Medication Reconciliation form identified "potential clinically significant medication issues" but failed to document what these issues were or how they were resolved - Staff education on medication reconciliation was only provided after the error was discovered, rather than as preventive training - The facility's pharmacy consultant was unaware of medication errors occurring at the facility - Communication challenges with the consulting pharmacy were attributed to high management turnover - The investigation of the medication error failed to identify all contributing factors, including the missed AMRR and laboratory communication failures
The resident himself confirmed the impact of the error during the inspection, stating that "he had been sent to the hospital at the end of March because he had missed doses of his anti-rejection medication and the transplant doctor wanted him to be monitored."
This case highlights the critical importance of robust medication management systems in nursing homes, particularly for residents with complex medical conditions requiring specialized medications. The failure to properly manage this transplant patient's immunosuppressive therapy could have resulted in irreversible organ damage or death, underscoring the life-threatening consequences that can result from seemingly routine administrative errors.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Longmeadow of Taunton from 2025-05-13 including all violations, facility responses, and corrective action plans.
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