The medication error at Sadie G. Mays Health & Rehabilitation Center harmed the resident, who had severe dementia and was receiving both Prozac and Lexapro simultaneously — a dangerous combination that can cause serotonin syndrome, according to her psychiatrist.
Federal inspectors found the facility continued giving the woman Prozac even though her psychiatrist discontinued it on June 29, 2023. The pharmacy kept dispensing the drug in pre-packaged medication strips, and nurses administered it daily without checking whether orders existed.
The resident's family filed multiple grievances about her deteriorating condition. When they visited on June 17, 2024, they found her weak, sick, moaning and crying. She had a low-grade temperature of 99 degrees and couldn't stand or walk, despite previously attending activities independently.
"Something was going on with R15 because R15 was usually up walking without any type of assistive device and was usually attending activities," the family told inspectors during a phone interview.
The facility failed to notify the family of these dramatic changes, though they quickly called when the resident was combative or refused medication, the family said.
Licensed Practical Nurse NN gave the resident Tylenol for knee pain on June 18, 2024, but inspectors found no physician order for the medication. During a medication pass observation two days later, the same nurse administered Prozac along with 12 other medications, including Lexapro.
The psychiatrist explained the danger of giving two selective serotonin reuptake inhibitors together. "It is dangerous to give a person two SSRIs due to it causing serotonin syndrome," he told inspectors. "It can cause insomnia, poor appetite, agitation, or restlessness."
He had discontinued Prozac because it was "potentially harmful drug in the elderly" and started the resident on Lexapro. When her condition continued declining, he switched her to Celexa, then back to Lexapro after a family conference.
"If the Prozac was never stopped that would explain the resident's continued decline," the psychiatrist said. "Receiving two SSRIs is not good."
The pharmacy dispensed Prozac daily from July 28, 2023, through June 20, 2024 — nearly a full year after discontinuation. A pharmacist said the first discontinuation order they received was on June 20, 2024, acknowledging "what happened was not purposely done, it was an accident."
The facility's Executive Director blamed the error on a pharmacy transition in August 2023, saying staff should have faxed the discontinuation order to both the old and new pharmacies.
In a separate case, inspectors found black gnats swarming around another resident's infected leg wound. The man had rheumatoid arthritis causing severe finger deformities and chronic pain, rating his discomfort between seven and nine on a 10-point scale.
During observations on May 2, 3, 7, and 8, 2024, inspectors saw gnats flying around and landing on the resident's leg wound dressing, which was saturated with reddish-brown drainage. The resident said gnats had "always been a problem in the room."
A wound care physician confirmed seeing gnats during previous visits, explaining the wound's moisture attracted them. Licensed Practical Nurse OO admitted the facility had gnat problems for two years but never reported it until inspectors brought it to her attention.
The Unit Manager said she was unaware of the infestation until surveyors pointed it out on May 2 and 3, then immediately notified maintenance.
Maintenance Director QQ claimed he checks pest control logbooks daily and had only seen dead roaches, not gnats. He said May 2, 2024, was the first time anyone told him about gnats in the facility.
However, Licensed Practical Nurse LL said she had never heard of pest control logbooks and reported maintenance concerns through an electronic system instead.
Inspectors also found two nursing assistants who worked with expired certifications — one for six months, another for 30 days. The facility blamed a previous education coordinator for failing to track renewals.
A registered nurse worked one day with a lapsed Georgia license before quitting without notice. Human Resources Director admitted responsibility for the oversight, saying she should have verified the license before hiring.
The facility failed to obtain signed consent forms before administering COVID-19 vaccines to two residents, despite having a policy requiring education and consent documentation.
During a medication observation, a registered nurse used the same blood pressure cuff on multiple residents without cleaning it between uses, then picked up an item from the floor and continued administering medications without washing her hands.
The 155-bed facility received citations for actual harm in medication management and pharmaceutical services, with additional violations for staff qualifications, infection control, pest control, and vaccination procedures.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sadie G. Mays Health & Rehabilitation Center from 2024-06-26 including all violations, facility responses, and corrective action plans.
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