GREENVILLE, SC - A recent inspection at The Gables of Pelham Skilled Nursing & Rehab revealed that staff administered an incorrect long-acting antipsychotic medication to a dementia patient for 17 days, despite the medication being ordered as a one-time dose only.
Critical Medication Error Puts Resident at Risk
The inspection documented a significant medication administration error involving a resident with Alzheimer's disease who received the wrong formulation of the antipsychotic drug Haldol. The facility administered Haldol Decanoate, a long-acting injectable medication typically given monthly, instead of regular short-acting Haldol that was prescribed for one-time use.
According to the inspection report, the resident received three doses of the long-acting medication between December 21 and December 29, 2024. The medication remained active on the resident's chart for 17 consecutive days without proper monitoring for adverse effects or behavioral changes.
The error originated when a Licensed Practical Nurse contacted the on-call Nurse Practitioner about a resident exhibiting "exit seeking behavior, entering patient rooms and is in constant need of redirection." The Nurse Practitioner ordered a single 10mg injection of regular Haldol, but due to a pharmacy transcription error, the facility received and administered Haldol Decanoate instead.
During interviews, the Nurse Practitioner confirmed the error, stating: "Regular Haldol is not the same as Haldol Decanoate, it's usually given once a month. They gave the wrong medication, and confirmed she ordered the Haldol 10 mg, as a 1 time dose only."
Understanding the Medical Significance
The distinction between regular Haldol and Haldol Decanoate is medically critical. Regular haloperidol is a short-acting medication that typically works for 6-24 hours, allowing for precise dosing adjustments and rapid discontinuation if adverse effects occur. Haldol Decanoate, however, is a long-acting depot injection designed for patients requiring prolonged antipsychotic therapy, with effects lasting approximately one month.
This difference becomes particularly concerning for elderly patients with dementia, who face increased mortality risks when treated with antipsychotic medications. The manufacturer's recommendations explicitly state that "antipsychotic drugs are at an increased risk for death" in elderly patients with dementia-related psychosis.
The facility's electronic system generated multiple safety warnings, including a Black Box warning and an alert indicating "the frequency of daily exceeds the usual frequency of every 28 days." Despite these alerts, staff proceeded with administration without recognizing the medication error.
Medical protocols require careful assessment before initiating any antipsychotic medication in dementia patients. Healthcare providers must evaluate the resident's mental, cognitive, behavioral, and physical status, considering alternative interventions before resorting to psychotropic medications. The facility's own policy emphasized using "the least restrictive alternative for the least amount of time."
Systematic Failures in Medication Management
The inspection revealed multiple breakdowns in the facility's medication management system. The Director of Nursing acknowledged during interviews that she was unaware the medication had been ordered for longer than 14 days without a proper diagnosis. She stated that "the physician should give the diagnosis and the nurses should ask."
The pharmacy consultant explained that facilities can access emergency medication kits after hours for non-controlled substances without direct pharmacy oversight. However, this system relies heavily on nursing staff recognizing medication discrepancies and following proper protocols.
The Pharmacy Director confirmed the transcription error, stating: "The medication was a 1-time only order, not every 8 hours. I'm not sure where that came from." This admission highlights gaps in communication between the prescribing provider, pharmacy, and nursing staff.
Perhaps most concerning was the absence of required monitoring protocols. The facility's care plan specifically stated the resident should be "free of drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment." Yet no documentation existed showing staff monitored for these potential adverse effects during the 17-day period.
Missing Safeguards and Consent Procedures
The inspection also identified failures in obtaining proper consent for psychotropic medication use. The Director of Nursing revealed that their Social Services Director, responsible for obtaining psychotropic medication consents, "was not doing that" during the time period in question.
Federal regulations require facilities to obtain informed consent before administering psychotropic medications to residents, particularly given the increased mortality risks in elderly dementia patients. This consent process ensures families understand the risks and benefits of treatment and have input into care decisions.
The facility's policy required thorough assessment before psychotropic medication initiation, including evaluation of alternative interventions that might address the underlying causes of behavioral symptoms. Non-pharmacological approaches such as environmental modifications, structured activities, and addressing physical discomfort are considered first-line interventions for dementia-related behaviors.
Industry Standards and Best Practices
Current medical standards emphasize a conservative approach to antipsychotic use in dementia care. The Centers for Medicare & Medicaid Services has implemented initiatives to reduce unnecessary antipsychotic use in nursing homes, recognizing that these medications often provide limited benefit while carrying significant risks.
Best practices include comprehensive behavioral assessments, identification of triggers for concerning behaviors, implementation of person-centered interventions, and careful risk-benefit analysis before considering medication interventions. When psychotropic medications are deemed necessary, protocols require starting with the lowest effective dose, frequent monitoring for side effects, and regular reassessment of continued need.
The medication error at this facility represents multiple system failures that could have been prevented through proper staff training, enhanced communication protocols, and robust monitoring systems. The long-acting nature of Haldol Decanoate meant the resident was exposed to medication effects for weeks beyond the intended treatment period.
Additional Issues Identified
The inspection documented several other concerning findings related to the facility's medication management practices. Staff failed to implement proper monitoring protocols for adverse effects, despite having established care plans addressing potential complications. The facility also lacked adequate oversight of emergency medication kit usage and failed to ensure proper communication between prescribing providers and nursing staff.
Documentation reviews revealed gaps in progress notes regarding the resident's response to medication and behavioral interventions. The facility's quality assurance processes failed to detect the medication error despite multiple system alerts and warnings generated by their electronic health record system.
The resident involved in this incident was subsequently discharged to another facility on January 6, 2025. Following the inspection, facility leadership implemented immediate corrective measures including staff education on psychotropic medication regulations and enhanced monitoring protocols for residents receiving antipsychotic medications.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Emeritus At Greenville from 2025-02-10 including all violations, facility responses, and corrective action plans.
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