Resident #3 was supposed to receive Tacrolimus twice daily — 2mg each morning and 2.5mg each evening — to prevent her body from rejecting the transplanted organ. The medication wasn't delivered on November 14, and nurses failed to secure replacement doses until November 21, when the Assistant Director of Nursing finally called the lung transplant clinic to report the missed medications.
The Director of Nursing told state inspectors on December 30 that she contacted the pharmacy to determine why the medication never arrived. The pharmacy blamed a "mistake with the courier service" for the delivery failure.
For a full week, nobody at the facility followed up on the missing medication. The resident went without her evening dose on November 14 and missed additional doses before staff intervened. Anti-rejection medications like Tacrolimus require precise timing to maintain therapeutic levels in transplant patients' bloodstreams.
The facility's own medication error report, completed by the Director of Nursing on November 21, documented that the "medication not delivered by back up, missed 2 doses, and 11/14/25 PM dose was late." The report noted that "the pharmacy did not order medication pick up in their system."
Windmill Manor's medication policy, last revised in February 2004, requires nurses to document any medication that cannot be given and circle the missed time on the Medication Administration Record. But the policy provides little guidance for pursuing missing medications or contacting physicians about critical missed doses.
Following the incident, the facility conducted an emergency in-service training for all nurses and medication aides on November 21. The training established new protocols: when medication is unavailable, certified medication aides must alert the nurse immediately and "never mark unavailable."
The new procedures require nurses to check the facility's emergency medication supply first, then call the pharmacy if the drug isn't available. If the pharmacy arranges backup delivery that doesn't arrive within two hours, nurses must call again. The training emphasized that nurses must notify both the physician and the resident's family about any missed doses.
The Director of Nursing told inspectors that facility nurses should have kept calling the pharmacy or notified leadership when the medication didn't arrive. She characterized the missed doses as a medication error requiring physician notification, family contact, and incident documentation.
But the training revealed systemic gaps in medication management. Certified medication aides were instructed to alert nurses when giving the last dose of any medication so replacements could be ordered before the next dose was due. Staff were told to call after-hours numbers to arrange backup pharmacy deliveries when necessary.
The facility's 21-year-old medication policy lacks specific procedures for handling delivery failures or pursuing missing critical medications. The policy's objective statement promises to provide residents with "those medications deemed necessary by the physician to improve and/or stabilize specified diagnosis," but offers minimal guidance for achieving that goal when systems fail.
State inspectors found the incident represented minimal harm with potential for actual harm, affecting few residents. But for transplant patients, missed anti-rejection medications can trigger rejection episodes that damage or destroy transplanted organs.
The November incident exposed how communication breakdowns between the facility, pharmacy, and courier service can leave vulnerable residents without life-sustaining medications. While Windmill Manor implemented new training and monitoring procedures, the resident had already gone a week without her prescribed anti-rejection therapy.
The facility's corrective action plan included education for staff and enhanced monitoring, but inspectors noted the delayed response to the missing medication. By the time the Assistant Director of Nursing contacted the lung transplant clinic, the patient had missed multiple doses of medication essential for preserving her transplanted lung.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Windmill Manor from 2025-12-30 including all violations, facility responses, and corrective action plans.