Bayview Rehab: Unnecessary Drug Regimen Cited - RI
The patient at Bayview Rehabilitation and Healthcare Center was admitted in November 2025 with blood clots in the leg and received a physician's order for warfarin 3 milligrams daily through November 13. Warfarin prevents dangerous clots from forming or growing larger.
On November 14, the patient received a PT/INR blood test as ordered by the physician. The test measures how quickly blood clots and determines whether warfarin dosing should continue or change. Results came back the same day.
But nobody reviewed the lab results. Nobody notified the physician. Nobody obtained a new warfarin order.
The patient missed warfarin doses on November 14 and 15.
Medication records show the patient had received warfarin daily since admission, except for those two days. Staff didn't transcribe a "Coumadin Alert" order until November 17 — three days after the missed doses.
The alert system requires evening shift staff to verify a current warfarin order exists before administering the medication. It documents the patient's INR results and current dose each shift.
Registered Nurse Staff A told inspectors during a December 1 interview that she was the patient's nurse on November 14. She said the PT/INR results may not have come back before her shift ended.
She couldn't provide evidence of any progress note addressing the lab results from November 14. She also couldn't show that anyone obtained a warfarin order on November 14 or 15.
The Director of Nursing acknowledged during her December 1 interview that the Coumadin Alert order should have been transcribed earlier. She confirmed the patient didn't receive warfarin on November 14 or 15.
The nursing director explained that the alert system ensures staff know when residents receive warfarin therapy. But she admitted the facility didn't implement the alert until November 17.
For patients on warfarin, missing doses can have serious consequences. The medication prevents blood clots that can cause strokes or pulmonary embolisms. Patients with deep vein thrombosis face particular risks when anticoagulant therapy is interrupted.
The inspection found that Bayview failed to ensure residents remain free from significant medication errors. Federal inspectors cited the facility under regulations requiring proper medication management.
The violation received a "minimal harm or potential for actual harm" rating. Inspectors noted the error affected few residents, but the specific patient faced increased risks during the two-day gap in treatment.
Warfarin requires careful monitoring because the therapeutic window between effective treatment and dangerous bleeding is narrow. The PT/INR test results guide physicians in adjusting doses or continuing therapy at current levels.
When facilities fail to follow up on these critical lab results, patients can experience either inadequate anticoagulation that allows clots to form or excessive thinning that causes bleeding complications.
The November incident at Bayview illustrates how communication breakdowns between nursing staff and physicians can leave vulnerable patients without essential medications. The facility's delayed implementation of its own alert system compounded the problem.
Staff interviews revealed gaps in the facility's medication oversight procedures. The registered nurse's uncertainty about lab result timing and the nursing director's acknowledgment of the delayed alert system suggest systemic issues beyond this single case.
The patient's medication administration record shows the gap in warfarin therapy occurred during a critical period when continuous anticoagulation was medically necessary to prevent clot progression.
Federal inspectors completed their investigation on December 1, documenting the medication error as part of a complaint inspection. The facility now faces potential enforcement action for failing to maintain medication safety standards.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bayview Rehabilitation and Healthcare Center from 2025-12-01 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Bayview Rehabilitation and Healthcare Center in North Kingstown, RI was cited for violations during a health inspection on December 1, 2025.
Warfarin prevents dangerous clots from forming or growing larger.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.