Colonial Park Rehabilitation and Nursing Center failed to monitor vancomycin levels for Resident #1, who required daily blood draws due to kidney problems. The powerful antibiotic can cause nephrotoxicity — kidney poisoning — if levels climb too high.
The cascade of delays began April 14, 2025, when pharmacy staff called about a missing blood draw. The facility promised to collect the specimen April 16.
Two days later, staff claimed the lab sample "sat too long" and scheduled another draw for April 21. By then, the resident's vancomycin levels had spiked to dangerous heights, requiring emergency hospitalization and immediate discontinuation of the medication.
"If they had had the trough levels, they would have stopped the medication," Physician #1 told inspectors during an October interview. The doctor had ordered the six-week vancomycin course and expected blood monitoring every three days for this resident with kidney impairment.
Assistant Director of Nursing #7 couldn't locate any laboratory results from April 14, despite facility records indicating labs were drawn April 15. The only vancomycin level they found was from April 18 — four days after the original order.
The timing proved critical. Vancomycin troughs must be drawn exactly one hour before the next dose to measure the lowest drug concentration in the bloodstream. Resident #1 received vancomycin at 9:00 AM and 9:00 PM, meaning blood draws should occur at 8:00 AM.
But staff proposed drawing blood at 1:00 PM or 4:00 PM — completely inappropriate timing that would produce falsely elevated results.
"The 1:00 PM or 4:00 PM draw would not be appropriate," Assistant Director of Nursing #7 acknowledged. "If the trough was not done at the appropriate time it could result in a higher value due to the timing of the dose completion."
Director of Nursing #3 admitted the facility had clear protocols. Registered nurses knew vancomycin troughs "should be drawn before the next dose was given." The hospital discharge paperwork outlined the monitoring requirements.
Yet nobody could explain why the April 14 blood draw never happened.
"They did not know why it was not done," Director of Nursing #3 told inspectors. "If the resident had an order for a vancomycin draw on 04/14/2025, it should have been drawn."
The facility's lab schedule complicated monitoring. Blood specimens went to the laboratory only Monday, Wednesday, and Friday, with orders placed in three-day windows. A phlebotomist drew blood for most residents, but registered nurses handled draws from peripherally inserted central catheters like Resident #1's.
This resident required the more intensive monitoring because of existing kidney problems. Physician #1 explained that vancomycin levels between 40-50 micrograms per milliliter "could cause renal impairment, regardless of pre-existing kidney disease."
"Waiting four days to draw a trough was not acceptable and they should have been notified," the physician said.
The delayed monitoring meant staff administered multiple doses of a potentially toxic medication without knowing if levels had already reached dangerous concentrations. Each missed day increased the risk of permanent kidney damage.
Registered Nurse #5 described the facility's blood draw process during an October interview. Nurses collected specimens from central catheters, completed lab orders, then called for pickup. The system required coordination between nursing staff, phlebotomists, and the external laboratory.
But the coordination failed catastrophically for Resident #1. Four days of vancomycin accumulated in their system while staff made promises, rescheduled draws, and claimed specimens had spoiled.
By April 21, the damage was measurable. The resident's vancomycin trough had climbed to levels requiring immediate hospitalization. The medication that was supposed to cure their infection had become the primary threat to their health.
The resident spent additional days in the hospital while their kidneys processed the excess vancomycin — time that could have been avoided with a single blood draw on April 14, as originally ordered.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Colonial Park Rehabilitation and Nursing Center from 2025-12-01 including all violations, facility responses, and corrective action plans.