FORT GAINES, GA - A federal inspection at Fort Gaines Health and Rehab documented serious medication management failures that left a resident with schizoaffective disorder without her prescribed antidepressant for nearly six months.
Antidepressant Medication Discontinued in Error
The inspection revealed that a resident with schizoaffective disorder, epilepsy, and anxiety disorder had her duloxetine (Cymbalta) medication mistakenly discontinued on September 26, 2024. The 30-milligram antidepressant, which she had been receiving twice daily since May 2022, was abruptly stopped without proper medical protocols.
According to inspection documents, the error remained undetected until March 24, 2025, when the facility's consultant pharmacist discovered the mistake during a routine monthly medication review. This meant the resident went without her prescribed mental health medication for approximately six months.
The facility's Director of Nursing confirmed during interviews that the medication was "mistakenly discontinued" by the facility's former Medical Director, and that "no orders were written for the resident to receive duloxetine after the medication was discontinued."
Dangerous Withdrawal Risks Ignored
Medical protocols require antidepressants like duloxetine to be gradually reduced rather than stopped abruptly. The facility's current Medical Director stated that "duloxetine should not be discontinued cold turkey because a resident needs to be weaned off the medication because there were side effects that could occur with it being discontinued abruptly."
The facility's Pharmacist Supervisor explained that stopping duloxetine suddenly can cause withdrawal symptoms including nausea, vomiting, and dizziness. The resident's current physician confirmed proper discontinuation protocols, stating: "If I wanted to decrease Cymbalta from 30 mg to completely taking her off of the medication, I would not stop it abruptly. I would have tapered her off of it by decreasing the dosage to 30 mg every other day for a month, then 15 mg every other day for a month."
Mental Health Provider Unaware of Change
Compounding the medication error, the facility's Mental Health Nurse Practitioner continued documenting that the resident was receiving duloxetine and that it was helping control her depression symptoms, even though the medication had been stopped months earlier.
The practitioner acknowledged during the inspection that he "had worked with the resident for years and was not aware that her Duloxetine medication was discontinued until March 2025." He admitted to erroneously documenting that the resident was receiving the medication and that it was effective for her symptoms.
The practitioner stated it "would have been prudent of him to review the resident's medications at each of his visits to see what medications the resident was receiving" and that while he "would have expected staff to inform him that the resident's antidepressant medication was discontinued, it was his responsibility to review the residents' medications as part of his evaluation."
Confusing Medication Orders Create Additional Risks
The inspection also documented problems with unclear medication orders for another resident prescribed the antipsychotic medication ziprasidone (Geodon). A physician's order written on September 9, 2024, contained conflicting instructions, stating both "give one capsule by mouth two times a day" and "give one capsule by mouth three times a day."
Nursing staff administered the medication twice daily from September through December 2024 without seeking clarification from the prescribing physician. The confusion wasn't resolved until December 2, 2024, when a new order specified the correct three-times-daily dosing.
Facility Response and Oversight Failures
A medication incident report dated March 24, 2025, indicated the pharmacy consultant questioned why the duloxetine was no longer active on the electronic medication administration record. The report noted that "the medical director mistakenly discontinued medication and failed to notify facility."
The facility's current physician was not informed of the error until six months after it occurred, stating: "I was not made aware of this until six months later, that the mistake was made by another doctor that mistakenly discontinued it."
The Director of Nursing acknowledged that facility nurses should "clarify any questionable physician order, which included when a physician discontinued a resident's antidepressant medication abruptly." She confirmed that nursing staff received additional training on clarifying physician orders after the error was discovered.
Patient Safety Standards Compromised
Federal regulations require nursing homes to ensure residents receive medications according to physician orders and professional standards of practice. The documented failures at Fort Gaines Health represented violations of medication management protocols designed to protect vulnerable residents.
Antidepressant medications require careful monitoring and gradual dose adjustments to prevent withdrawal symptoms and maintain therapeutic benefits. Abrupt discontinuation can trigger discontinuation syndrome, characterized by flu-like symptoms, dizziness, and potential worsening of underlying mental health conditions.
For residents with complex mental health diagnoses like schizoaffective disorder, consistent medication management is particularly critical for maintaining stability and preventing psychiatric symptoms from recurring.
Resident Impact Assessment
During the inspection, the affected resident reported feeling "a little more tired than normal" over recent months but had not experienced increased depression or sadness. The Mental Health Nurse Practitioner noted he "had not noticed a change in the resident's mood or an increase in her depression during the past months."
A behavioral health note dated April 25, 2025, documented that the resident's "depression is stable" and that "she tolerated the discontinuation well." However, this assessment came only after the error was discovered and did not account for the potential risks the resident faced during the six-month period without prescribed medication.
Systemic Communication Breakdowns
The inspection revealed multiple communication failures within the facility's care team. The prescribing physician was unaware of the medication discontinuation, the mental health provider continued documenting treatment with a discontinued medication, and nursing staff failed to question the abrupt cessation of an antidepressant.
These breakdowns highlight the importance of integrated care coordination in nursing home settings, where multiple providers must communicate effectively to ensure resident safety and appropriate treatment outcomes.
The documented violations resulted in minimal harm classifications but demonstrated significant potential for adverse outcomes given the medical complexity of the affected residents and the critical nature of psychiatric medications in their treatment plans.
Fort Gaines Health and Rehab is located at 101 Hartford Road West in Fort Gaines, Georgia. The facility must submit a plan of correction addressing the identified medication management deficiencies to state and federal regulators.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Fort Gaines Health and Rehab from 2025-04-30 including all violations, facility responses, and corrective action plans.
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