Resident 148 arrived at HeritageSpring Healthcare Center of West Chester expecting to receive Eliquis, an anticoagulant prescribed for their atrial fibrillation. Instead, nurses working from an incomplete fax never entered the medication into the system. The resident developed pulmonary embolism and died shortly after being rushed to the hospital.
The facility's lead administrator confirmed that the hospital notified them of the medication error after the resident's death. Federal inspectors found that even pages of the critical fax had gone missing, and multiple staff members who reviewed the orders according to protocol failed to catch the potentially fatal oversight.
RN 16 made the initial mistake during the admission process. She told inspectors that when reviewing orders uploaded into the facility's computer system, she found an outdated medication list for Resident 148. Knowing the resident would arrive soon, she called the transferring facility and requested they fax current orders.
"She stated she entered the medication orders from the fax but did not notice that pages were missing," inspectors wrote. The resident's family brought a packet containing the complete orders when they arrived, but by then the incomplete transcription was already in the system.
The nurse documented that she had verified the orders with Nurse Practitioner 360, following standard protocol. A unit manager double-checked the orders within 24 hours as required. Neither caught the missing medication.
NP 360 told inspectors she reviewed Resident 148's medication orders and conducted a chart review within 24 hours of admission, as facility policy required. She said the resident's diagnosis of atrial fibrillation would not have automatically triggered her to expect anticoagulant therapy, given the patient's age and other medical conditions.
"She recalled that after the resident was sent to the hospital, they discovered the resident was not receiving a blood thinner," the inspection report stated.
The nurse practitioner acknowledged the medication error but stopped short of definitively linking it to the resident's death. She told inspectors that Resident 148 had multiple medical conditions that contributed to developing pulmonary emboli, and while not receiving Eliquis "did not help," it was difficult to say with certainty that the missing medication caused the death.
Medical Director 550 offered a similar assessment when questioned by inspectors. He confirmed that Resident 148 never received Eliquis during their stay at the facility, but said he could not state "with 100 percent certainty" that the missing anticoagulant caused the fatal pulmonary embolism.
The facility's director of nursing told inspectors that staff failed to receive complete admitting orders for Resident 148, creating a transcription error when nurses worked from the incomplete fax. Her expectation, she said, was that nurses verify all pages were received before entering orders.
The assistant director of nursing confirmed there were transcription errors involving Resident 148 but could not provide additional details to inspectors. He said admission nurses were responsible for transcribing orders, ensuring all pages and orders were received, and verifying orders with the medical director.
The administrator described the systematic failure that led to the resident's death. Two nurses reviewed Resident 148's orders as protocol required, and a supervisor reviewed the medical record the following day. None of the three staff members identified the missing pages or the absent blood thinner prescription.
During a follow-up interview, the administrator told inspectors that he expected staff to review orders and ensure all pages were received at the time of admission. The hospital's notification about the medication error revealed that even-numbered pages of the fax had never arrived at the nursing home.
Facility policies obtained by inspectors showed clear requirements for medication order handling. A policy revised in March 2025 instructed staff to review hospital transfer paperwork and enter admission medication orders into the electronic medical record, including medication name, dose, route of administration, and frequency.
The policy also required staff to verify admission orders with attending physicians, nurse practitioners, or physician assistants, then print an order summary report after verification and place a copy in the resident's chart.
A separate policy from November 2024 stated that the facility would ensure patients received medications per physician orders. If nurses identified any issues with physician orders, they were required to contact the physician for clarification.
The resident had chosen conservative medical management before arriving at HeritageSpring Healthcare. Their treatment preferences included no cardiopulmonary resuscitation, no intubation, and comfort-focused care. Despite these end-of-life wishes, the prescribed Eliquis represented standard medical care for their atrial fibrillation diagnosis.
Federal inspectors classified the medication error as immediate jeopardy to resident health and safety, the most serious level of violation in nursing home oversight. The designation indicates that facility practices created a situation where residents faced serious injury, harm, impairment, or death.
The case emerged from a complaint investigation, suggesting that someone with knowledge of the incident reported the facility to state health officials. Complaint investigations typically focus on specific allegations rather than comprehensive facility reviews.
Resident 148's family brought complete medication orders with them on admission day, but the transcription error had already occurred. The resident spent their final days at the facility without the blood thinner that might have prevented the clots that formed in their lungs, ultimately leading to their death at the hospital where the medication error was finally discovered.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Heritagespring Healthcare Center of West Chester from 2025-11-19 including all violations, facility responses, and corrective action plans.
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