PLAINFIELD, IN - A medication error investigation at Plainfield Health Care Center revealed significant safety violations after a resident with dementia was repeatedly found wearing two doses of a powerful dementia medication simultaneously, according to federal inspection records from February 2025.
Dangerous Medication Error Pattern Emerges
The most serious violation at Plainfield Health Care Center involved multiple instances of medication overdose with rivastigmine (Exalon) patches, a transdermal medication used to treat dementia symptoms. The resident, identified as Resident Q, was discovered on at least two separate occasions wearing two patches simultaneously - a potentially life-threatening medication error.
According to the inspection report, the first incident occurred on December 25, 2024, when the resident's wife arrived to take him home from the facility. She discovered he was wearing two Exalon patches on his body. When emergency room staff examined the resident upon his arrival at the hospital that day, they documented finding "two patches/doses of Rivastigmine on him" at 12:19 p.m.
The medication error pattern continued during the resident's second stay at the facility. On January 1, 2025, the resident's wife again discovered two rivastigmine patches on her husband during a visit. The inspection narrative notes that "the wife was upset because the resident had two patches of rivastigmine, one dated and one not dated."
The facility's response to these discoveries raised additional concerns. According to the resident's wife, when she reported the December incident, "the Administrator, Director of Nursing Services, and the nurse all told her it was not a medication error to have two Exalon patches on" - a statement that contradicts established medication safety protocols.
Medical Risks of Rivastigmine Overdose
Rivastigmine belongs to a class of medications called cholinesterase inhibitors, which work by preventing the breakdown of acetylcholine in the brain. When administered in excessive doses, these medications can cause severe and potentially fatal complications.
The manufacturer guidelines for rivastigmine patches specifically warn that "overdosage with cholinesterase inhibitors can result in cholinergic crisis characterized by severe nausea, vomiting, salivation, sweating, bradycardia, hypotension, respiratory depression, collapse, and convulsions." The guidelines further state that "increasing muscle weakness is a possibility and may result in death if respiratory muscles are involved."
For residents with dementia, who may already have compromised communication abilities and underlying health conditions, medication overdoses pose particularly serious risks. The inability to clearly express symptoms of toxicity makes early detection challenging, potentially allowing dangerous side effects to progress unnoticed.
Proper medication administration protocols require that old patches be removed before applying new ones. The rivastigmine patches are designed to deliver medication continuously over 24 hours, making the removal of previous patches essential to prevent dangerous accumulation of the drug in the patient's system.
Facility Policy Failures and Documentation Issues
The inspection revealed significant gaps in the facility's medication administration protocols. While Plainfield Health Care Center had policies requiring staff to remove old patches before applying new ones, these protocols were not consistently followed or properly documented.
The facility's own policy, titled "Transdermal Drug Delivery System (Patch) Application," clearly states that staff should "observe site of previous application" and "if patches are continuous remove existing patch and cleanse site." The policy also requires documentation of the "site of administration to ensure rotation process."
However, interviews with facility staff revealed that documentation of patch locations was not standard practice. The Director of Nursing Services indicated that "neither order from both of his stays included documentation of where the patches had been applied, and it was not their policy to document where they apply medication patches."
This lack of documentation created conditions where multiple patches could be applied without staff awareness of existing medication. The Regional Nurse Consultant acknowledged that during the resident's first stay, medication orders included requirements for staff to sign off on patch removal, but during his second admission, "the order did not include the task that required staff to sign off that indicated to take the patch off."
The facility did complete medication error reports following the January 1 incident, documenting both a "transcription error" for failing to include patch removal documentation and an "other medication related error" for failing to remove the old patch when applying the new one.
Medical Record and Inventory Violations
Beyond the medication errors, inspectors identified significant deficiencies in the facility's medical record keeping and medication inventory procedures. The facility failed to maintain proper documentation of medications brought to the facility by residents and failed to follow established protocols for medication disposition upon discharge.
When Resident Q was discharged against medical advice on January 1, 2025, the facility did not complete required admission or discharge inventory lists for his medications. The resident's wife had brought many of his medications from home when he was admitted, but the facility lacked documentation of what medications were received upon admission.
Federal regulations require nursing homes to maintain detailed records of all medications, including those brought by residents from home. These inventory requirements serve multiple purposes: preventing medication errors, ensuring proper storage and security, and providing accountability for controlled substances.
During the resident's discharge, the facility only documented the return of 43 clonazepam tablets, a controlled substance, requiring the resident's wife to sign for receipt. However, no documentation existed for the counting or return of any other medications, despite the resident having multiple prescriptions including antidepressants, sleep aids, and other dementia medications.
Industry Standards and Required Protocols
Medication safety in nursing homes is governed by strict federal regulations requiring facilities to implement comprehensive safeguards against medication errors. These standards mandate multiple verification steps, proper documentation, and staff training on medication administration procedures.
For transdermal patches specifically, industry best practices require visual inspection of the skin before application, removal of any existing patches, rotation of application sites, and clear documentation of both application and removal. These protocols are designed to prevent the exact type of overdose that occurred at Plainfield Health Care Center.
The facility's admission and discharge procedures must also meet federal standards for medication inventory and disposition. These requirements ensure continuity of care and prevent medication-related complications during care transitions.
Additional Issues Identified
The inspection identified several other areas of concern related to medication management and record keeping. Staff training gaps were evident in the inconsistent application of patch removal protocols between the resident's two stays at the facility. The lack of standardized documentation for patch application sites created opportunities for errors to go undetected.
The facility's response to family concerns also raised questions about staff understanding of medication safety principles. The initial dismissal of the double-patch situation as "not a medication error" suggests inadequate training on the serious risks associated with medication overdoses.
Communication protocols between clinical staff and families appeared insufficient, as evidenced by the repeated occurrences of the same medication error and the family's continued concerns about medication management. The facility's policies for discharge against medical advice also showed gaps in implementation, particularly regarding medication inventory and disposition requirements.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Plainfield Health Care Center from 2025-02-20 including all violations, facility responses, and corrective action plans.
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