The patient, identified as Resident #5 in federal inspection records, was hospitalized in April after blood tests revealed dangerously low therapeutic drug levels of immunosuppressants. The medications prevent the body's immune system from attacking transplanted organs.
Federal inspectors found the nursing home failed to follow the patient's March 11 hospital discharge summary, which specifically ordered two anti-rejection medications: Sirolimus 0.5 mg tablet every 24 hours and Tacrolimus 2 mg capsules every 24 hours.
A review of the facility's physician orders and medication administration records for March and April showed no orders for either drug. The patient simply never received them.
The error came to light during a discussion between the resident's cardiologist and facility staff on April 23. Blood work had revealed the therapeutic drug levels were too low, indicating the patient hadn't been taking the prescribed medications. The cardiologist requested immediate hospital transfer for evaluation and treatment.
Certified Registered Nurse Practitioner #16, who handles admissions, gave conflicting accounts of her responsibilities during a telephone interview with inspectors. She initially said she reviews hospital discharge summaries and reconciles medications for new residents, explaining that she doesn't change or stop any medications listed on discharge orders.
But when pressed about Resident #5 specifically, the nurse practitioner said she doesn't have access to medication administration records and that reconciling medications is actually the admitting nurse's responsibility.
"I was focused on the resident's heart failure medications," she told inspectors when asked if she noticed the heart transplant patient wasn't receiving any anti-rejection drugs.
The Director of Nursing confirmed that admitting nurses place medication orders, but said providers are expected to reconcile the medication list. Neither happened properly for the heart transplant patient.
Anti-rejection medications are among the most critical drugs a transplant recipient can take. Without them, the immune system will attack the new organ as foreign tissue, potentially causing rejection that can be fatal. Maintaining consistent therapeutic levels in the blood is essential for transplant success.
The facility reported the incident through two separate facility reported incidents, numbers 365430 and 365429, acknowledging the medication error had occurred.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm to some residents. The inspection was conducted October 9 following a complaint about the facility.
Layhill Nursing and Rehabilitation Center operates at 3227 Bel Pre Road in Silver Spring. The facility is required to submit a plan of correction addressing how it will prevent similar medication reconciliation failures.
The case highlights a critical gap in the admission process, where a patient's most essential medications fell through cracks between nursing and provider responsibilities. For a heart transplant recipient, those weeks without immunosuppressants represented a potentially life-threatening oversight that required emergency medical intervention to address.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Layhill Nursing and Rehabilitation Center from 2025-10-09 including all violations, facility responses, and corrective action plans.
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