The medication error occurred December 19 at Summerhill Elderliving Home & Care when Licensed Practical Nurse CC asked a resident if his name was either his own or another resident's last name. The patient incorrectly stated the other resident's name.
LPN CC looked at a photo on the medication administration record for the other resident, which she said resembled the patient in front of her. She then gave that resident's oral medications to the wrong person.
The nurse realized her mistake only when she arrived at the correct resident's room to give medications to his roommate. She found the intended recipient lying in his bed wearing different clothing than expected.
The patient who received the wrong medications was sent to the hospital emergency room and admitted for observation due to what medical records described as "polypharmacy and syncopial episode."
Hospital emergency department records show the patient was seen by a physician at 12:15 pm on December 19.
LPN CC was relieved of her medication cart at 11:50 am that same day and sent home following the error.
But after losing access to medications and leaving the facility, LPN CC documented administering 10 additional drugs to the hospitalized patient between 12:44 pm and 12:45 pm.
The falsely documented medications included docusate sodium 100 milligrams, GlycoLax powder, Linzess 72 micrograms, probiotic oral capsule, Zetia 10 mg, Klor-Con 20 milliequivalents, Lasix 40 mg, metoprolol succinate extended release 25 mg, amlodipine besylate 2.5 mg, and chewable aspirin 81 mg. All were scheduled for 9:00 am administration.
The documentation occurred nearly 30 minutes after hospital records show the patient was already being treated by emergency department physicians.
During interviews with federal inspectors, RN Supervisor EE confirmed that the Education Nurse took the keys to the medication cart before 11:30 am on December 19, and that LPN CC was removed from the hall but could still access documentation systems.
The Director of Nursing told inspectors that when she spoke with LPN CC by phone after the medication error, the nurse did not indicate she had given the patient his own medications later in the day.
"She thought LPN CC signed items off on the MAR before she left the facility because the items were signed off after 12:00 pm," inspectors wrote.
The Education Nurse confirmed during a January 13 interview that she took over the medication cart from LPN CC on December 19.
LPN CC's personnel file showed she had between mid-level and advanced-level experience with medication administration and advanced-level experience in nursing home settings, according to clinical competency testing evaluations.
Her job description specified that she was expected to administer medications using the "five Rights of Medication Administration and two patient identifiers" as a principle duty and responsibility.
Facility policy required nurses to document all medications on each resident's electronic medication administration record immediately as medications are being administered to individual residents.
The policy, dated March 22, 2017, stated that administration of medication must be documented immediately as medication administration is being done per individual resident.
Federal inspectors found the facility failed to ensure services provided by the licensed nurse met professional standards of quality, including accurate documentation of medication administration.
The violation affected one resident from a total sample of 11 residents reviewed during the January 28 complaint investigation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Summerhill Elderliving Home & Care from 2025-01-28 including all violations, facility responses, and corrective action plans.
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