The resident, identified as Resident #2, was admitted to Parkview Care Center on September 19 with a complex medical history including surgical aftercare, colostomy status, pulmonary embolism, and malignant neoplasm of the colon. Hospital discharge orders included apixaban, a blood thinner prescribed at five milligrams twice daily to prevent dangerous clots.
The medication was sitting in the facility's automated dispensing machine the entire time.
Licensed Practical Nurse #174 worked alone during her 12-hour overnight shift on September 19. She told the resident that medications "probably would not arrive until the middle of the night," unaware that apixaban was already available in the building's medication system.
"She was never provided authorized access to the automated medication dispensing machine to pull any medications for the resident," according to the inspection report. The nurse admitted she never notified the physician that medications wouldn't be administered.
The resident went without the evening apixaban dose on September 19 and again on September 20.
The Director of Nursing confirmed that LPN #174 lacked authorization to access the medication machine. During interviews, she revealed the nurse "could have notified her and she would have came into the facility to get the medication for the resident."
Nobody called.
Licensed Practical Nurse #162, who had assessed the resident upon admission around 5:35 P.M. on September 19, said she "had not had time to enter her physician medication orders prior to the end of the shift." The resident's pharmacy delivery arrived the next day, September 20, but the evening dose was missed again.
For a patient with pulmonary embolism, missing blood thinner doses can have serious consequences. Apixaban prevents blood clots from forming or growing larger, particularly crucial for someone recovering from cancer surgery and already dealing with clots in the lungs.
The facility's medication administration records documented the gap. The resident missed the prescribed apixaban doses on both September 19 and September 20, despite physician orders clearly requiring the medication twice daily.
LPN #160 confirmed during interviews that apixaban was available in the automated medication distribution machine throughout the period when doses were missed.
The facility's policy on administering oral medications, last revised in October 2010, simply states to "administer medications per physician orders." Inspectors found no guidelines for notifying physicians when medications are unavailable, even though in this case the medication wasn't actually unavailable.
The breakdown revealed a communication failure across multiple shifts. The admitting nurse didn't enter orders before leaving. The overnight nurse worked alone without system access and didn't call for help. The Director of Nursing wasn't notified despite being available to come in.
No one told the physician about the missed doses.
The resident had intact cognition according to the admission assessment, meaning they likely understood the importance of their prescribed medications. Federal inspectors reviewed three residents' medication records during this complaint investigation and found significant errors affecting one of them.
Parkview Care Center, with a census of 36 residents, failed to ensure this resident remained free from significant medication errors. The facility's automated systems and policies created barriers rather than safeguards, leaving a vulnerable patient without prescribed treatment during a critical recovery period.
The inspection was conducted in response to Complaint Number 2627398, though the specific nature of the original complaint wasn't detailed in the available records.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Parkview Care Center from 2025-10-09 including all violations, facility responses, and corrective action plans.