Ingleside Manor Cited for Widespread Medication Administration Failures
MOUNT HOREB, WI - State inspectors found serious medication management problems at Ingleside Manor, where residents experienced dangerous delays in receiving critical medications and an error rate exceeding 64 percent during routine medication administration.
Critical Medication Delays Compromise Patient Safety
The March 14, 2025 inspection revealed a pattern of medication administration failures that placed residents at risk. State surveyors documented that residents received time-sensitive medications hours beyond their prescribed schedules, with some medications becoming unavailable entirely.
One resident with pulmonary hypertension and high blood pressure reported receiving her 8:00 AM medications as late as 12:30 PM on multiple occasions. "I received my 8:00 AM medications well after 9:00 AM," the resident told inspectors, describing incidents on March 10-11, 2025. She reported experiencing chest pain and needing to request emergency nitroglycerin when her blood pressure medications were delayed.
The facility's own policy requires medications to be administered within one hour of their prescribed time. However, inspection records show critical medications for blood pressure, diabetes, and heart conditions were routinely administered 2-4 hours late, well beyond acceptable medical standards.
Dangerous Error Rate Exceeds Safety Thresholds
During direct observation, inspectors documented an alarming 64.28 percent medication error rate - more than twelve times the maximum acceptable threshold of 5 percent. Out of 28 medication administration opportunities observed, staff made 18 errors, affecting three of the four residents monitored.
The errors primarily involved timing violations for medications that require precise scheduling to maintain therapeutic effectiveness. Blood pressure medications, insulin for diabetes management, and heart medications were among those administered outside safe timeframes.
Medical Consequences of Delayed Medications
Blood pressure medications require consistent timing to maintain stable cardiovascular control. When medications like hydralazine and carvedilol are delayed by hours, patients face increased risk of hypertensive episodes, stroke, and cardiac complications. The facility resident who reported chest pain demonstrates how delayed blood pressure medications can trigger acute symptoms requiring emergency intervention.
Diabetes medications present particularly serious timing concerns. Insulin administration must coordinate precisely with meals to prevent dangerous blood sugar fluctuations. Inspectors observed a diabetic resident receiving both short-acting and long-acting insulin nearly two hours late, creating risk for hypoglycemia or hyperglycemia.
Heart failure medications like furosemide must maintain consistent blood levels to manage fluid retention and prevent cardiovascular complications. Delayed administration can lead to fluid buildup, breathing difficulties, and increased hospitalization risk.
Systemic Staffing and Supply Chain Issues
The inspection revealed multiple underlying causes for the medication failures. Staff reported being "pulled to do other things" during medication administration times, and new employees expressed feeling overwhelmed by the workload. One nurse on her second day at the facility was observed running significantly behind schedule with seven residents still waiting for 8:00 AM medications at 9:00 AM.
Supply chain problems compounded the timing issues. Staff reported medications being documented as "drug item unavailable" and having to contact out-of-town pharmacies for emergency supplies. The facility's contingency medication supply proved inadequate, and not all staff had access to emergency medications when needed.
Industry Standards and Required Protocols
Federal regulations require nursing homes to maintain medication error rates below 5 percent and ensure medications are administered according to physician orders. The facility's own policies acknowledge these standards, stating medications must be given within one hour of scheduled times unless otherwise specified.
Professional nursing standards emphasize that medication administration requires uninterrupted focus and adequate staffing. Time-sensitive medications like insulin, blood pressure medications, and cardiac drugs require particular attention to timing because their therapeutic windows directly impact patient safety.
Additional Issues Identified
The inspection documented several related problems that contributed to the medication management failures:
- Inadequate staffing during peak medication administration periods - Insufficient emergency medication supplies in the facility's contingency stock - Limited access to backup medications for agency or temporary staff - Poor coordination with external pharmacy providers - Lack of protective protocols to prevent interruptions during medication administration - Inadequate training for new staff members handling complex medication regimens
The Director of Nursing confirmed the late medication administrations during the inspection, acknowledging that the facility failed to meet its own established standards for timely medication delivery.
These violations occurred at a 53-bed facility serving residents with complex medical conditions requiring precise medication management. The state's complaint investigation focused specifically on pharmaceutical services after receiving reports of medication administration problems.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ingleside Manor from 2025-03-14 including all violations, facility responses, and corrective action plans.
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