The resident at Hamilton Park Nursing and Rehabilitation Center was prescribed 225 milligrams of Venlafaxine daily — a combination of two different strengths taken at different times. Electronic records show the medication wasn't given on February 7, 8, 17, 18, 19, and 20, with an additional evening dose missed on February 18.
Licensed Practical Nurse #3 administered medications during most of those missed days. They told inspectors the Venlafaxine "was not in the cart" and had been missing "for over 3 or 4 days." The nurse didn't inform the charge nurse or physician that the medication was unavailable.
They finally reported it to supervisors on February 20.
The facility's own care plan required staff to "monitor and document side effects and effectiveness every shift" for this resident's antidepressant use. No such monitoring occurred during the two-week period when doses were missed.
Nurses wrote progress notes on February 7, 8, 18, and 19 documenting that Venlafaxine was "on order." One note from February 18 said they were "waiting for pharmacy." Another that evening said "awaiting pharmacy."
But the pharmacy wasn't the problem.
The pharmacist told inspectors that Venlafaxine had been refilled multiple times during the period in question. The 75-milligram strength was restocked on January 21, February 16, and February 21. The 150-milligram strength was refilled February 9, 21, and 23.
"There was no reason for the resident to not receive Venlafaxine because they refilled the medication," the pharmacist said. "Medications were sent as ordered and is possible the medications were misplaced."
The pharmacy did experience a computer outage on February 19, but it was resolved the next day. The pharmacist said the resident missing medication "has nothing to do with the glitch in the system since the glitch was resolved the next day."
Licensed Practical Nurse #2 worked the day shift on February 17 when another dose was missed. They told the charge nurse the medication wasn't available but "cannot recall if they followed up with the pharmacy or if they endorsed it to the next shift."
Licensed Practical Nurse #1 worked the evening shift February 18 when the bedtime dose was skipped. They contacted the pharmacy and reported to the nursing supervisor that the medication wasn't available, but didn't notify the physician.
The charge nurse on duty February 20 said Licensed Practical Nurse #3 asked if any medications had been delivered to the unit, "but was not told that the medication was not available or missing."
The physician learned about the missed doses only when inspectors arrived.
"They were made aware a few days ago that Resident #102 was not administered Venlafaxine, and they instructed the staff to call the pharmacy to get a STAT delivery," Physician #1 told inspectors on February 25. "They had not received a call on the earlier dates that Venlafaxine was not available."
The Director of Nursing was also unaware. "They were not aware that Resident #102's Venlafaxine was not administered due to not being available," according to the inspection report. The director said nursing supervisors are trained to contact physicians when medications aren't available "to see if an alternative can be suggested."
The Assistant Director of Nursing learned about the situation the same day as inspectors. They said there was "a glitch in the pharmacy system causing delays in dispensing the medications" and that the Venlafaxine was "now en route from the pharmacy as a STAT order."
None of the nurses monitored the resident for adverse effects from the missed antidepressant doses. Venlafaxine withdrawal can cause dizziness, nausea, headache, irritability, and flu-like symptoms. The resident had intact cognition according to their assessment, meaning they would be aware of any withdrawal effects.
No medication error report was completed for the missed doses.
The facility's medication policy requires drugs to be "administered in safe and timely manner, and as prescribed." When medications are withheld or missed, staff must document the reason with corresponding codes on the administration record.
But inspectors found a separate food safety violation that same week. A resident with a documented mushroom allergy received cream of mushroom soup on their lunch tray February 18. The allergy was highlighted in red at the bottom of the meal ticket, but multiple dietary staff missed it during the tray line process.
The resident's family member removed the soup before it was consumed.
"Multiple staff double checked the resident's tray and meal ticket and everyone including the final checker missed the allergy," the Dietary Director told inspectors.
Two dietary aides said they weren't trained to check for allergies listed on meal tickets. One said "it is the nurse who checks for allergies."
That same day, inspectors observed a nursing assistant handling lettuce with bare hands while preparing a sandwich for another resident, violating food safety protocols.
The nursing assistant initially denied touching food with bare hands, then said they "used wipes to clean their hands" and washed before handling the bread. The facility's policy requires staff to "avoid bare-hand contact with ready to eat foods" and use gloves or serving utensils.
A separate infection control violation occurred during wound care for a resident with a stage 3 pressure ulcer. Licensed Practical Nurse #4 removed a soiled dressing, then cleaned the wound without changing gloves or performing hand hygiene between the contaminated and clean portions of the procedure.
"Hand hygiene is supposed to be performed after removing the soiled dressing and before cleaning the wound," Registered Nurse #4 explained after the observation.
The Director of Nursing said hand hygiene should occur "after removing the soiled dressing, then again after cleaning the wound and also before applying the treatment and clean dressing."
All violations were classified as causing minimal harm or potential for actual harm. The medication errors affected some residents, while the food safety and infection control issues affected few residents.
The resident who missed antidepressant doses for nearly two weeks continues to rely on staff who couldn't locate medication that the pharmacy says was delivered.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hamilton Park Nursing and Rehabilitation Center from 2025-02-25 including all violations, facility responses, and corrective action plans.
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