MOUNT AIRY, MD - Federal inspectors documented serious medication safety violations at Lorien Health Systems Mt Airy after a nurse simultaneously prepared medications for two different residents, resulting in a dangerous medication error that required emergency hospitalization.
The February 20, 2025 inspection revealed the facility failed to implement adequate safeguards to prevent medication errors and lacked proper protocols for feeding tube management across multiple residents.
Critical Medication Mix-Up Leads to Emergency
On April 2, 2023, Registered Nurse #108 prepared medications for two residents simultaneously - a practice that directly violated standard medication administration protocols. The nurse took both medicine cups, each labeled for different residents, to the first patient's room.
According to the facility's incident report, the nurse administered Resident #12's medications to Resident #8 before realizing the error. This mistake had severe consequences, as the medications were completely inappropriate for the recipient's medical condition.
Resident #8, who had diastolic congestive heart failure, prosthetic heart valve, atrial fibrillation, stroke history, mitral valve insufficiency, and diabetes, received three blood pressure-lowering medications plus an anticoagulant (blood thinner) not prescribed for their condition. The resident's vital signs that morning were 105/68 - below the threshold for administering blood pressure medication, meaning they should have received no cardiovascular medications at all.
Dangerous Cardiac Complications Follow Error
The medication error created an immediate medical emergency. Resident #8 received multiple blood pressure medications when their readings were already dangerously low, plus an anticoagulant that significantly increased bleeding risk.
Following physician notification of the error, Resident #8 was immediately transferred to the hospital for monitoring and remained there for four days. During hospitalization, the resident experienced repeated episodes of tachycardia (heart rate above 100) and bradycardia (heart rate below 60) - dangerous heart rhythm abnormalities directly related to the incorrect medications.
Hospital physicians recommended pacemaker implantation to regulate the resident's heart rhythm, though the family declined the procedure due to the resident's age. A pacemaker is an implantable device that sends electrical impulses to maintain proper heart rhythm when natural regulation fails.
Medical Significance of the Error
Blood pressure medications work by reducing the heart's pumping force and dilating blood vessels. When given to someone with already low blood pressure, these drugs can cause dangerous drops in circulation, potentially leading to organ damage from inadequate blood flow.
Anticoagulants prevent blood clotting and are prescribed for specific medical conditions like atrial fibrillation or history of blood clots. When given to patients not requiring blood thinning, these medications dramatically increase bleeding risk, particularly internal bleeding that can be life-threatening.
The combination of inappropriate blood pressure medications and anticoagulants created a perfect storm of cardiovascular complications, explaining the resident's subsequent heart rhythm disturbances and need for intensive hospital monitoring.
Standard Medication Safety Protocols Violated
Healthcare facilities are required to follow strict medication administration protocols known as the "Five Rights": right patient, right medication, right dose, right route, and right time. The nurse's practice of preparing medications for multiple residents simultaneously violated these fundamental safety principles.
Current best practices mandate that nurses prepare medications for only one resident at a time, verify patient identity using two identifiers, and double-check all medications against physician orders before administration. These protocols exist specifically to prevent the type of error that occurred at Lorien Health Systems Mt Airy.
During the inspection, LPN #68 and RN #107 confirmed they do not prepare medications for multiple residents simultaneously, indicating staff awareness of proper protocols. However, the facility's failure to prevent the April 2023 incident suggests inadequate supervision and enforcement of medication safety standards.
Feeding Tube Management Deficiencies Identified
Inspectors also found significant deficiencies in feeding tube care protocols. The facility lacked proper procedures for managing percutaneous endoscopic gastrostomy (PEG) tubes - feeding tubes surgically inserted through the abdominal wall directly into the stomach.
Review of six residents with PEG tubes revealed systemic problems in five cases. Resident #6's case highlighted these deficiencies when their PEG tube became dislodged on February 3, 2024. RN #54 replaced the tube with a 20 French tube and inflated the balloon with 15ml of water, following telephone consultation with the on-call physician.
However, inspection revealed the facility's gastrostomy policy was undated and contained no requirements for X-ray confirmation of tube placement - a critical safety measure to ensure proper positioning before resuming feeding.
Missing Physician Orders Create Safety Gaps
Medical record review revealed absent or incomplete physician orders for PEG tube specifications across multiple residents. Residents #16, #17, and #18, all dependent on PEG tubes for nutrition and medication administration, had no orders specifying tube replacement protocols or monitoring requirements.
Resident #4 had conflicting orders noting two different PEG tube sizes, creating confusion about proper replacement specifications. Only Resident #6 had appropriate orders, placed reactively after the tube dislodgement incident rather than proactively as part of routine care planning.
These missing orders create significant safety risks. PEG tubes must be properly sized and positioned to prevent complications including aspiration pneumonia, peritonitis from misplaced tubes, or inadequate nutrition delivery.
Regulatory Requirements and Industry Standards
Federal regulations require nursing facilities to ensure residents receive medications without significant errors and provide appropriate care for medical devices like feeding tubes. Facilities must maintain current, comprehensive policies addressing all aspects of resident care.
The Centers for Medicare & Medicaid Services expects facilities to implement robust quality assurance programs that identify potential safety risks before they harm residents. This includes regular policy updates, staff competency verification, and systematic monitoring of medication administration practices.
Professional nursing standards emphasize medication safety as a core competency requiring ongoing education and supervision. The Joint Commission and other accrediting bodies have identified medication errors as a leading cause of preventable patient harm in healthcare facilities.
Inspection Findings and Compliance Issues
The February 20, 2025 inspection was conducted in response to complaints about both incidents. Inspectors assigned F760 violations for medication errors and F693 violations for inadequate feeding tube care, both classified as "minimal harm or potential for actual harm" affecting few residents.
However, the severity of consequences - including a four-day hospitalization and consideration for pacemaker implantation - demonstrates the potentially life-threatening nature of these "minimal" violations when safety protocols fail.
The facility's Director of Nursing and Nursing Home Administrator were notified of all findings throughout the inspection process and during the exit conference, indicating management awareness of the compliance issues requiring immediate attention.
Lorien Health Systems Mt Airy must submit a plan of correction addressing all identified deficiencies to continue participating in Medicare and Medicaid programs. The plan must demonstrate specific measures to prevent recurrence of medication errors and establish comprehensive feeding tube management protocols.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lorien Health Systems Mt Airy from 2025-02-20 including all violations, facility responses, and corrective action plans.
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