Inspection Report

Santa Monica Conv Ctr I: Blood Thinner Failure, CA

October 24, 2025

Santa Monica, CA

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SANTA MONICA, CA - Ocean Park Healthcare on Pico Boulevard faced serious medication management violations during an April inspection, with state surveyors documenting the facility's failure to administer a prescribed blood thinner to a resident with atrial fibrillation and multiple cardiac conditions.

Critical Medication Error Discovered

The inspection revealed that a resident with atrial fibrillation, a dangerous irregular heartbeat condition, did not receive their prescribed apixaban (Eliquis) blood thinner medication despite having an active physician's order. The resident had been transferred from Greater Los Angeles Community Hospital (GACH) on February 14, 2025, with clear documentation showing the blood thinner was part of their required medication regimen.

Medical records showed the resident had multiple serious cardiac conditions, including atherosclerotic heart disease, a history of stroke, and a cardiac pacemaker. For patients with atrial fibrillation, blood thinners are essential medications that prevent potentially fatal blood clots from forming. These clots can travel to the brain, causing strokes, or to other vital organs.

The medication was never transcribed to the facility's Medication Administration Record (MAR) for February 2025, meaning nursing staff had no record to follow for administering the drug. During the inspection, Licensed Vocational Nurse 1 acknowledged the serious consequences, stating that "the likely outcome for missing a blood thinner medication, the resident will have blood clots and complications that risks Resident 1's life."

Breakdown in Medication Reconciliation Process

The violation highlighted significant failures in the facility's medication reconciliation system, which is designed to ensure continuity of care during patient transfers. According to facility policy, nursing staff must compare hospital discharge medication lists with facility admission orders to prevent medication errors.

Multiple staff members were involved in the breakdown. The admitting Registered Nurse stated they "did not complete reconciliation because the resident was admitted after the RN's end of shift" and endorsed the admission process to the evening charge nurse. Licensed Vocational Nurse 3, who was responsible for entering medications into the electronic system, acknowledged that apixaban was listed in the transfer orders but admitted, "it might be an honest mistake omitting the apixaban/Eliquis from Resident 1's MAR."

The attending physician confirmed providing telephone approval for the resident's existing transfer medications, including the blood thinner, but the medication was never properly processed by nursing staff.

Medical Significance of Blood Thinner Therapy

Atrial fibrillation affects millions of Americans and significantly increases stroke risk. Patients with this condition have irregular heartbeats that can cause blood to pool in the heart's chambers, forming dangerous clots. Blood thinners like apixaban work by interfering with the body's clotting process, reducing the likelihood of clot formation by approximately 60-70% when taken consistently.

The consequences of missing blood thinner doses can be severe and immediate. Even short interruptions in anticoagulation therapy can allow clots to form within 24-48 hours. For patients with multiple risk factors like this resident - who had atrial fibrillation, previous stroke history, and heart disease - the risk becomes exponentially higher.

According to established medical protocols, blood thinner therapy should never be interrupted without careful medical supervision and usually requires bridging with other anticoagulants during any planned interruptions. Unplanned interruptions, like the one documented at this facility, represent serious patient safety events.

Systemic Issues in Medication Management

The inspection revealed broader problems with the facility's medication reconciliation system. The pharmacy supervisor confirmed they never received an order for the blood thinner, explaining that "pharmacy cannot dispense without orders." This indicates the error occurred during the initial medication transcription process rather than at the pharmacy level.

The facility's Director of Nursing acknowledged that "the medication is possibly omitted due to a failure to transcribe and medication reconciliation." This admission points to systemic issues in staff training, oversight procedures, and quality assurance measures during the critical admission process.

Standard nursing home protocols require that medication reconciliation be completed within 24 hours of admission, with supervisory review to catch any transcription errors. The facility's own policy mandates that nursing supervisors or the Director of Nursing review medication reconciliation after each admission, but this oversight apparently failed to occur.

Additional Issues Identified

The inspection also noted that the resident's Minimum Data Set assessment incorrectly indicated that high-risk anticoagulant medications were "not assessed," despite the resident being prescribed such medication. This represents an additional documentation failure that could have triggered appropriate monitoring protocols.

The facility's medication reconciliation policy, revised in April 2024, clearly outlines procedures for comparing external medication lists with facility orders, but the implementation of these procedures proved inadequate in this case.

These violations demonstrate critical gaps in medication safety protocols that nursing homes must maintain to protect vulnerable residents with complex medical conditions requiring precise medication management.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Santa Monica Conv Ctr I from 2025-04-22 including all violations, facility responses, and corrective action plans.

Additional Resources

Editorial Standards

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: August 5, 2026 · Our methodology

Quick Answer

OCEAN PARK HEALTHCARE in SANTA MONICA, CA was cited for violations during a health inspection on April 22, 2025.

For patients with atrial fibrillation, blood thinners are essential medications that prevent potentially fatal blood clots from forming.

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.

Frequently Asked Questions

What happened at OCEAN PARK HEALTHCARE?

For patients with atrial fibrillation, blood thinners are essential medications that prevent potentially fatal blood clots from forming.

How serious are these violations?

Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.

What should families do?

Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in SANTA MONICA, CA, (5) Report any new concerns directly to state authorities.

Where can I see the full inspection report?

The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from OCEAN PARK HEALTHCARE or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 555786.

Has this facility had violations before?

To check OCEAN PARK HEALTHCARE's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.