The September incident at Santa Cruz Post Acute involved a resident scheduled for right ureteroscopy, a procedure to treat kidney stones that may require laser surgery and placement of a flexible tube to help urine drain from the kidney to the bladder.
Her doctor's notes from August 11 were explicit: "Stop Eliquis 3 days before surgery." The resident had been taking apixaban, sold under the brand name Eliquis, twice daily since March to prevent blood clots. The anticoagulant thins blood, creating bleeding risks during surgery.
The resident was originally scheduled for surgery on September 2 at 7:30 a.m., with transportation arranged for 5:15 a.m. pickup. Staff properly stopped giving her Eliquis on September 1 and 2, following the pre-operative instructions.
But transportation never arrived.
The missed appointment was rescheduled for September 8. That's when the communication breakdown occurred.
From September 3 through September 8, nursing staff resumed giving the resident Eliquis twice daily. No one had told them the rescheduled surgery required the same three-day medication hold.
On September 8, the resident was transported to her 6 a.m. appointment for the 7:30 a.m. procedure. The surgery was canceled when medical staff discovered she had been receiving the blood thinner.
"There was some miscommunication when it was rescheduled and there was no order to discontinue Eliquis prior to the 9/8/25 appointment," the director of nursing told inspectors on September 9. "It should have been communicated to the nurses."
The facility's own policy requires physicians to evaluate residents scheduled for surgery, with particular attention to "identifying significant medication-related risks" including "stopping anticoagulation."
But the director of nursing revealed a gap in the facility's processes. Resident appointments are typically reviewed during morning meetings with department heads, she explained, but the September 8 appointment wasn't discussed.
"There was no process to review Monday appointments that are added to the calendar on a Friday afternoon," she said. "I did not know about the appointment until 9/8/25."
The receptionist had learned about the rescheduled appointment from the resident's family member. She arranged transportation and added the September 8 surgery to the resident calendar, but the critical pre-operative medication instructions fell through the cracks.
The medication administration records show the precise timeline of the error. Eliquis was properly withheld on September 1 and 2 for the original surgery date. After the missed appointment, staff resumed the twice-daily doses from September 3 through September 8, the day of the canceled procedure.
For a resident needing kidney stone treatment, the delay meant continued discomfort and potential complications. Kidney stones can cause severe pain, urinary blockages, and infections if left untreated.
The ureteroscopy procedure the resident was scheduled to receive uses a thin scope inserted through the urethra and bladder to reach the kidney. If stones are found, surgeons can break them up with laser energy. A ureteral stent, essentially a small flexible tube, is often placed to keep the ureter open and allow urine to flow properly while the area heals.
Continuing blood thinners before such procedures creates serious bleeding risks. The medication prevents normal clotting, which could lead to dangerous hemorrhaging during or after surgery.
Federal inspectors found the facility failed to provide services meeting professional standards of quality. The violation was classified as causing minimal harm or potential for actual harm, but highlighted systemic communication failures that could affect other residents.
The resident had to wait additional days for her rescheduled procedure, enduring continued symptoms while the blood thinner cleared her system. The facility's admission that it lacked processes for weekend-scheduled Monday appointments suggested other residents could face similar delays or complications.
The inspection occurred after a complaint was filed about the facility's care. The specific details of who filed the complaint and when were not disclosed in the inspection report.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Santa Cruz Post Acute from 2025-11-26 including all violations, facility responses, and corrective action plans.