Resident 56's first biopsy appointment on October 1 was scrapped after staff served him breakfast that morning, despite orders requiring him to fast. The second attempt on October 9 was canceled when nurses discovered they had been giving him blood-thinning medications for days when the drugs should have been stopped.
The resident's bone marrow biopsy was ultimately delayed three weeks.
RN 200 had provided clear instructions to the facility: hold the resident's Eliquis and aspirin for three days before the October 9 procedure. But when she called the facility on October 8 to verify the pre-procedure orders were being followed, she learned staff had continued administering both medications.
Medical records confirmed the facility gave Resident 56 his aspirin and Eliquis on October 6, 7, and 8. The bone marrow biopsy had to be rescheduled for a second time.
Licensed Practical Nurse 305 told inspectors the facility's system created delays in critical medical information. "The facility did not have hard/paper charts, so there were delays in uploading important documents into the electronic medical record," she said during an October 20 interview.
The nurse confirmed both failures. Resident 56 ate before his first appointment, and the second appointment was canceled "due to staff administering aspirin and Eliquis to Resident 56, and not holding it for three days prior, as instructed."
Communication between nursing shifts relied entirely on verbal reports and handwritten sheets, LPN 305 explained. When residents returned from appointments with new procedure orders, staff placed the information in the medication administration record and notified the physician. But the system broke down for Resident 56.
Director of Nursing interviews revealed the scope of the communication failures. The floor nurse responsible for receiving Resident 56's bone marrow biopsy orders never entered the pre-procedure instructions into the electronic medical record for the October 1 appointment.
"There were no orders in the EMR for the pre-procedure instructions for the bone marrow biopsy scheduled for 10/01/25, resulting in staff providing the resident breakfast on 10/01/25 and cancellation of the procedure," the director confirmed.
The same pattern repeated for the October 9 appointment. Pre-procedure instructions weren't followed, staff continued the resident's blood thinners, and the procedure was rescheduled again for October 21.
The director acknowledged dietary staff received NPO orders verbally but said "there should be a more formal process in place to avoid potential issues, like in the case with Resident 56 being served his breakfast meal on 10/01/25."
RN Unit Manager 306 described how the system was supposed to work during her October 22 interview. When residents returned from appointments, nurses received after-visit packets containing new orders. The nurse caring for the resident was responsible for reviewing the information and entering orders into the electronic medical record.
"This was not completed for Resident 56's procedures," she confirmed.
The medication errors were particularly concerning given the nature of blood-thinning drugs before surgical procedures. Eliquis and aspirin increase bleeding risk, making it dangerous to perform biopsies when these medications remain in a patient's system. Standard medical practice requires stopping these drugs days before procedures to allow their effects to wear off.
Bone marrow biopsies are typically performed to diagnose blood cancers, bone marrow disorders, or monitor treatment progress. The three-week delay in Resident 56's procedure meant postponing potentially critical diagnostic information about his condition.
The facility's electronic medical record system, intended to improve care coordination, instead created gaps in communication. Critical pre-procedure orders never made it from paper instructions into the digital system where nursing staff could access them during medication administration.
Federal inspectors found the violations represented a pattern of poor communication and inadequate systems for managing procedure preparations. The failures affected medication administration, dietary restrictions, and care coordination between departments.
The investigation stemmed from a complaint filed under Master Complaint Number 2639137, suggesting concerns about the facility's medication management practices had reached federal regulators through external reports.
Resident 56's experience illustrated how administrative failures in nursing homes can directly impact medical care, turning routine pre-procedure preparations into weeks of delays and repeated cancellations.
Full Inspection Report
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