CHOCTAW, MS - A federal inspection conducted on March 6, 2025, at Choctaw Residential Center revealed multiple instances where nursing staff failed to follow fundamental medication safety protocols, resulting in residents receiving incorrect medications, discontinued drugs, and medications at improper times.
Critical Medication Errors Compromised Patient Safety
During the inspection, surveyors observed licensed practical nurses administering medications without verifying essential safety checks, leading to multiple medication errors that could have resulted in serious health consequences for vulnerable residents.
In one documented case, a licensed practical nurse administered Glipizide 10 mg to a diabetic resident on March 5, 2025, despite the medication having been discontinued two days earlier on March 3. The same nurse also gave an Albuterol sulfate inhaler at an incorrect time—the medication had already been administered at 6:00 AM but was given again at 8:15 AM, well before the scheduled six-hour interval. Additionally, the nurse documented administering a Mometasone Furoate inhaler that was never actually given to the resident.
The resident affected by these errors had been admitted with Type 2 Diabetes Mellitus and Chronic Systolic Congestive Heart Failure, conditions requiring precise medication management. When interviewed later that day, the nurse acknowledged making these errors and admitted to not verifying the six rights of medication administration before giving the medications.
The six rights of medication administration represent a fundamental safety protocol in nursing practice: ensuring the right resident receives the right drug in the right dosage via the right route at the right time, with right documentation. These checks serve as critical safeguards to prevent medication errors that can lead to adverse drug reactions, therapeutic failures, or medical emergencies.
Consequences of Administering Discontinued Diabetes Medication
The administration of Glipizide to a resident after discontinuation represents a particularly concerning violation. Glipizide is an oral medication used to control blood sugar levels in patients with Type 2 Diabetes. When a physician discontinues this medication, it typically indicates a change in the patient's treatment plan—perhaps due to the medication no longer being effective, causing adverse effects, or because blood sugar levels have changed.
Administering a discontinued diabetes medication can create dangerous situations. If the medication was stopped because the resident's blood sugar was running too low, giving an additional dose could precipitate hypoglycemia—a potentially life-threatening condition characterized by confusion, sweating, rapid heartbeat, and in severe cases, loss of consciousness or seizures. For elderly residents with heart conditions like Chronic Systolic Congestive Heart Failure, such episodes carry heightened risks.
The timing error with the Albuterol inhaler also posed significant risks. Albuterol is a bronchodilator used to treat breathing difficulties and is typically scheduled at specific intervals to maintain therapeutic levels while avoiding excessive dosing. Administering the medication too frequently can lead to increased heart rate, tremors, and elevated blood pressure—complications particularly dangerous for someone with congestive heart failure. The cardiovascular system of a patient with heart failure is already compromised, and overstimulation from excessive bronchodilator use could exacerbate their cardiac condition.
Wrong Medication Formulation Given to Dialysis Patient
In a second incident observed on the same day, another licensed practical nurse administered Aspirin Enteric Coated 81 mg to a resident when the medication record specified a chewable formulation should have been given. The resident had End-Stage Renal Disease and had been admitted to the facility on January 4, 2025.
While this might appear to be a minor distinction, the difference between enteric-coated and chewable aspirin formulations has clinical significance. Enteric coating prevents the medication from dissolving in the stomach, instead releasing it in the small intestine. This formulation is designed to reduce gastrointestinal irritation but results in delayed absorption. Chewable aspirin, by contrast, is absorbed more rapidly and may be specifically ordered when quicker onset of action is desired or when a patient has difficulty swallowing pills.
For patients with End-Stage Renal Disease, medication management requires exceptional precision. These patients often take aspirin for cardiovascular protection, as they face significantly elevated risks of heart attack and stroke. The kidney's inability to filter waste products properly means that medication effects can be prolonged or intensified, making adherence to prescribed formulations particularly important.
During her interview, the nurse acknowledged that she had not thoroughly checked the six rights of medication administration and stated that proper verification likely would have prevented the error. This admission highlights a systemic issue: nurses were not consistently following established protocols designed specifically to catch such discrepancies before medications reach patients.
Unsecured Medication Cart Created Access Risk
Beyond the administration errors, inspectors documented a separate but equally serious violation involving medication security. On March 3, 2025, at 12:45 PM, surveyors found a medication cart on C hall left unlocked and unattended with no nurse in sight.
Medication carts contain controlled substances, prescription medications, and other drugs that must be secured at all times when not under direct observation of authorized personnel. These carts represent a significant safety hazard when left accessible, as residents—including those with cognitive impairments—could access medications not prescribed to them.
The nurse responsible acknowledged she had been called away and forgot to lock the cart. When asked about the implications, she stated plainly that any resident could access the cart and take medications. The facility administrator confirmed during her interview that this created a situation where residents could obtain medications and potentially experience allergic reactions or other adverse events.
The risks associated with unsecured medications in a long-term care environment are substantial. Residents with dementia or cognitive decline may not recognize medications as potentially harmful and could ingest them out of curiosity or confusion. Others might intentionally take medications believing them to be their own. Controlled substances could be diverted. In all scenarios, the potential for serious harm exists—from adverse drug reactions and overdoses to dangerous drug interactions.
Facility policy explicitly required that medications remain under direct observation during administration or be locked in storage areas. The policy recognized that even brief lapses in security could create dangerous situations.
Understanding the Broader Context of Medication Safety
Medication errors represent one of the most common types of medical mistakes in healthcare settings, and nursing homes face particular challenges due to the complexity of resident needs. Many long-term care residents take multiple medications—a situation known as polypharmacy—which increases both the complexity of medication administration and the potential for errors.
Professional nursing standards and federal regulations require specific protocols to minimize these risks. The six rights of medication administration evolved from decades of research into how errors occur and how they can be prevented. Each right serves as a checkpoint: verifying the resident's identity prevents giving medications to the wrong person; checking the drug name prevents mix-ups between similar-sounding medications; confirming dosage prevents over- or under-dosing; verifying the route ensures medications are given correctly; checking the time maintains therapeutic schedules; and proper documentation creates an accurate record.
When nurses bypass these verification steps, the safety net fails. In healthcare, these failures often result from system issues rather than individual negligence—factors like understaffing, inadequate training, distractions during medication passes, or workflow pressures can all contribute to errors. However, regardless of contributing factors, the consequences for residents remain serious.
Additional Issues Identified
The inspection report documented violations of federal Tag F658, which requires facilities to ensure that medication administration follows professional standards and that the six rights of medication administration are consistently followed. The violations affected multiple residents and occurred across different nursing staff, suggesting the problems were not isolated to a single individual but reflected broader compliance issues within the facility's medication management system.
The facility also violated Tag F761, which mandates that drugs and biologicals be stored in locked compartments and that controlled drugs be separately secured. This violation was classified as affecting few residents but represented a minimal harm or potential for actual harm situation that could have escalated had residents accessed the unsecured medications.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Choctaw Residential Center from 2025-03-06 including all violations, facility responses, and corrective action plans.
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