FORT COLLINS, CO - Federal inspectors found that Poudre Canyon Rehabilitation and Nursing failed to protect residents from serious medication errors and inadequate abuse investigations during a May 2025 inspection.
Critical Medication Mix-Up Sends Resident to Emergency Room
The most serious violation occurred on April 29, 2025, when an 83-year-old dementia patient received four medications prescribed for another resident. The error resulted in severe hypotension requiring emergency hospitalization and intensive monitoring.
According to inspection documents, registered nurse RN #3 administered Lisinopril 20 milligrams, Metformin 500 milligrams, Seroquel 100 milligrams, and Ramelteon 8 milligrams to Resident #10 - none of which were prescribed for her. The patient's actual medication regimen included mirtazapine for depression, olanzapine for mental health conditions, tramadol for pain, and divalproex sodium for seizure control.
The medication error occurred because the nurse was unfamiliar with residents on the unit and failed to follow basic patient identification protocols. Resident #10 had no photograph in her electronic medical record and no name plate on her door - critical safety measures that should have prevented the mix-up.
Medical Impact and Emergency Response
The consequences were immediate and dangerous. Resident #10 developed severe hypotension with blood pressure readings dropping to 58/34 mmHg - well below normal ranges of 120/80 mmHg. The patient also experienced tachycardia (elevated heart rate) as her cardiovascular system struggled to compensate.
Emergency medical protocols required the patient to receive intravenous fluids and continuous monitoring at the hospital for six hours. Despite initial stabilization, her blood pressure dropped again during transport back to the facility, necessitating a second emergency room visit and additional observation.
The facility's pharmacist expressed immediate concern about the medication combination's potential effects. Lisinopril, a blood pressure medication, was particularly dangerous given the patient's already low baseline blood pressure. The pharmacist noted that typical starting doses for Lisinopril begin as low as 2.5 milligrams, making the 20-milligram dose administered potentially eight times higher than appropriate for an initial prescription.
Systemic Failures in Patient Safety Protocols
The investigation revealed multiple breakdowns in fundamental nursing safety practices. The nurse failed to verify the patient's identity using the "seven rights of medication administration" - a standard protocol requiring verification of the right medication, dose, patient, route, time, documentation, and indication.
Most concerning was the discovery that 17 residents facility-wide lacked either photographs in their electronic records or name identification on their doors. This represented a systemic failure in patient identification systems that created ongoing risks for similar medication errors.
The facility's own medication administration policy, revised just weeks before the incident in April 2025, specifically required nurses to "identify resident by photo in the MAR (medication administration record)" and follow the six rights of medication administration. The investigation concluded that "multiple facility systems failed" and there was "a deviation from the facility's policy and procedure."
Pattern of Medication Safety Concerns
Inspection records revealed this was not an isolated incident for the nurse involved. RN #3 had previously made a medication error on April 9, 2025, administering an incorrect dose of Lyrica to another resident. Despite receiving reminders about medication safety protocols after that first error, the more serious April 29 incident occurred just 20 days later.
The nurse reported experiencing concentration difficulties and cognitive symptoms that affected her work performance. The facility subsequently developed a performance improvement plan requiring the nurse to report any cognitive symptoms that might impact patient care and limited her assignments to units where she was more familiar with residents.
Inadequate Abuse Investigations Compromise Resident Safety
Federal inspectors also cited the facility for failing to conduct thorough investigations of alleged resident abuse. Two separate incidents highlighted significant gaps in the facility's investigation procedures.
In one case involving alleged inappropriate contact between a resident and her boyfriend, facility administrators failed to interview key witnesses and delayed implementing protective measures. The nursing home administrator acknowledged that investigation questions "did not make sense for the investigation process" and that the lack of proper interviews made it difficult to determine if allegations were substantiated.
A separate physical altercation between two residents on April 8, 2025, was inadequately investigated. Staff interviews lacked specificity about what witnesses observed, and investigators failed to interview the residents involved to understand potential triggers for the incident.
Medical Significance of Medication Errors
Medication errors in nursing homes pose particularly serious risks for elderly residents with multiple chronic conditions. Blood pressure medications like Lisinopril can cause life-threatening hypotension in patients not prescribed these drugs, especially those with baseline cardiovascular conditions.
For dementia patients, the risks are compounded by cognitive impairments that may prevent them from recognizing or reporting adverse symptoms. The combination of medications administered to Resident #10 created multiple physiological stresses simultaneously - cardiovascular effects from the blood pressure medication, potential blood sugar impacts from diabetes medication, and sedative effects from psychiatric medications.
Proper patient identification represents the most fundamental safety barrier against such errors. Electronic medical records with current photographs allow nurses to visually verify patient identity, while door nameplates provide secondary confirmation. The absence of both safeguards created a "Swiss cheese" effect where multiple safety barriers failed simultaneously.
Facility Response and Corrective Actions
Following the April 29 incident, Poudre Canyon implemented several corrective measures. All nursing staff received individual medication administration education focusing on the seven rights of medication administration. The facility updated its admission audit process to ensure timely addition of patient photographs and door identification.
The director of nursing implemented weekly audits of photo identification systems and medication administration observations. Random medication administration observations were increased to four to eight monthly reviews across all nursing staff.
For the nurse involved in the errors, the facility created a comprehensive performance improvement plan including weekly medication administration observations, supervisor check-ins, and assignment restrictions to familiar units. The plan requires the nurse to immediately report any cognitive symptoms that might affect patient care.
Regulatory Context and Industry Standards
The Centers for Medicare & Medicaid Services requires nursing homes to maintain medication error rates below five percent and eliminate significant medication errors that cause resident discomfort or jeopardize health and safety. The April 29 incident clearly met the definition of a significant medication error due to the hospitalization and potential health consequences.
Federal regulations mandate that nursing homes develop and implement policies ensuring medications are administered according to physician orders and accepted professional standards. The facility's own policies acknowledged these requirements but failed in practical implementation during the critical incident.
The inspection findings reflect broader challenges in nursing home medication safety nationwide. Complex medication regimens, staff turnover, and inadequate identification systems contribute to an estimated 40% of nursing home residents experiencing at least one medication error during their stay, according to healthcare quality research.
Poudre Canyon Rehabilitation and Nursing must submit a plan of correction detailing specific steps to address the identified deficiencies and prevent recurrence of medication errors and inadequate investigations.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Poudre Canyon Rehabilitation and Nursing, LLC from 2025-05-15 including all violations, facility responses, and corrective action plans.
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