Federal inspectors found that Savannah Post Acute LLC ignored its own care plan requirements for a resident taking Eliquis, a powerful anticoagulant prescribed after the patient suffered bilateral pulmonary embolism and deep vein thrombosis.
The resident's September medical assessment documented a cascade of serious conditions: blood clots in both lungs, a clot in the leg, stroke, and high blood pressure. On September 23, staff created a care plan specifically addressing the blood clot diagnoses, with interventions that included "administering medications as ordered and documenting side effects and effectiveness."
Five days later, doctors prescribed Eliquis at 10 milligrams daily for the first week, then 5 milligrams twice daily for over three months.
Nobody monitored for side effects.
Medication records from October show no documentation of staff watching for bleeding, bruising, or other complications from the blood thinner. The clinical record contained no evidence anyone tracked how the resident responded to the medication.
The oversight violated the facility's own policy requiring each medical discipline to handle "initiation and ongoing follow-up for care plans as related to their area of expertise."
During the October inspection, the facility's nurse practitioner confirmed that residents receiving anticoagulants "would need to be monitored for medication side effects." The Director of Nursing acknowledged that nurses were "expected to follow the care plan" and admitted there was "no documentation of monitoring for side effects from the anticoagulant."
Eliquis carries significant risks, particularly for elderly patients with multiple medical conditions. The medication can cause serious bleeding that requires immediate medical attention. Without proper monitoring, staff cannot identify early warning signs or adjust treatment before complications develop.
The resident's complex medical history made monitoring even more critical. Bilateral pulmonary embolism occurs when blood clots block arteries in both lungs, a potentially fatal condition. Deep vein thrombosis can lead to more clots traveling to the lungs or brain. Combined with a history of stroke, the resident faced elevated risks from both the underlying conditions and the medication treating them.
Federal regulations require nursing homes to develop comprehensive care plans that address each resident's individual needs and medical conditions. The plans must include specific interventions that staff can measure and implement consistently.
Savannah Post Acute's policy, dated February 1, 2024, explicitly assigned responsibility for care plan follow-up to each medical discipline. The nursing staff's failure to document medication monitoring represented a breakdown in this system.
The inspection revealed the gap between written protocols and actual practice. While the care plan correctly identified the need to monitor medication side effects and effectiveness, staff never translated those requirements into documented observations or assessments.
For residents on anticoagulants, monitoring typically includes checking for signs of bleeding, measuring clotting times through blood tests, and watching for interactions with other medications or foods. Documentation helps ensure continuity of care across nursing shifts and provides evidence that staff are actively managing medication risks.
The October medication records show Eliquis was administered as prescribed, but contain no notes about the resident's response to treatment. Clinical notes similarly lack any reference to anticoagulant monitoring during the period reviewed.
Federal inspectors classified the violation as having "minimal harm or potential for actual harm" affecting "few" residents. However, the failure to monitor blood-thinning medication in a patient with multiple clotting disorders and stroke history represented a serious gap in medical oversight.
The Director of Nursing's acknowledgment that no monitoring occurred confirmed the inspection findings. Her statement that nurses were expected to follow care plans highlighted the disconnect between facility expectations and actual nursing practice.
The resident continued receiving Eliquis throughout the inspection period without documented surveillance for the medication's effects or complications.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Savannah Post Acute LLC from 2025-11-18 including all violations, facility responses, and corrective action plans.