The September medication error at Evergreen Post Acute happened when nurse E27 pulled the wrong patient's pills from the medication cart at 8:15 AM, according to federal inspection records. The nurse later admitted she called out the roommate's name and gave the medications to the wrong woman when she responded.
"I said to R644, 'I have your medication' and she said I need my medication in pudding," the nurse wrote in her signed statement to investigators. "I did not know she was hard of hearing."
R644 had been admitted to the facility just one day earlier with heart failure and chronic obstructive pulmonary disease. Instead of receiving her prescribed medications — amlodipine 5 mg, clonidine 0.1mg, furosemide 40 mg and losartan 100 mg — she received her roommate's much stronger heart medications: amlodipine 10 mg, benzapril 40 mg, Coreg 25 mg and sevelamer 800 mg.
An hour after the 8:20 AM medication administration, staff checked R644's blood pressure and found it had plummeted to 65/26. By the time paramedics arrived at 9:48 AM, her blood pressure had dropped further to 50/20.
"The staff relayed that those medications are not prescribed for the patient and the patient was suppose to be given amlodipine 5 mg, clonidine 0.1mg, furosemide 40 mg and losaratan 100 mg," the EMT documented in the prehospital care report.
R644 spent approximately 16 hours in the hospital emergency room receiving IV fluids and having her vital signs monitored. She returned to the facility at 1:31 AM the following day with stabilized vital signs.
The emergency room doctor's visit summary stated: "You were seen here in the emergency room for your low blood pressure after taking the wrong medication. We did an evaluation that included blood work and gave you IV fluids."
The nurse who made the error was terminated on January 1, 2025, for failing to perform job requirements, according to facility records reviewed by inspectors.
Federal inspectors also found the facility failed to remove a medical device before discharging another patient home on hospice care. R644's daughter told investigators during an April phone interview that when her mother arrived home after discharge, "her PICC line was still in. It was supposed to be taken out at Evergreen prior to discharge."
The peripherally inserted central catheter should have been removed on October 2 when a nurse practitioner entered a discontinuation order. Staff had documented in discharge planning records that "PICC will be pulled by nursing," but the device remained in place when R644 left the facility three days later.
Inspectors documented additional safety failures involving infection control and fall prevention. A resident who had suffered a broken leg from a fall was supposed to have protective mats placed beside his bed, but staff failed to provide them on multiple inspection visits in April.
The resident had been readmitted in September with a right broken leg from a facility fall and was assessed as high risk for additional falls. His care plan specifically required fall mats at bedside when in bed, but inspectors found none during observations on April 8, April 11, and April 15.
"Fall mats should have been placed at the bedside while R35 was in bed," the Director of Nursing confirmed to inspectors, stating "the issue would be addressed immediately."
The facility also failed to follow federal infection control guidelines for residents with dangerous bacteria. One resident with a history of ESBL bacteria and a colostomy went eight months without required enhanced barrier precautions after new federal guidelines took effect in April 2024.
Another resident being treated for MRSA pneumonia with the antibiotic linezolid never received contact precautions during his three-week treatment period in October.
Inspectors observed contaminated waste bags sitting on floors and staff wearing dirty gloves between patient rooms. A nursing assistant was seen picking up a trash bag containing soiled briefs from one isolation room floor and carrying it across the hallway to another isolation room while wearing the same contaminated gloves.
"No this should not be, it should go directly to the biohazard room," the Director of Nursing told the aide after inspectors pointed out the violation.
R644's medication error resulted in actual harm to the patient, while the other violations were cited as having minimal harm or potential for actual harm. The facility completed corrective actions for the medication error by September 2024, but inspectors found ongoing compliance issues during their April 2025 complaint investigation.
The 83-year-old patient with heart failure who received the wrong medications had normal cognitive function, according to her admission assessment, making the communication breakdown with the hard-of-hearing resident particularly concerning for patient safety protocols.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Evergreen Post Acute from 2025-04-17 including all violations, facility responses, and corrective action plans.