LEXINGTON, SC — A nurse at Retreat at Wellmore of Lexington gave a resident triple her prescribed antidepressant dose for five consecutive days, sending her to the hospital where doctors discovered she had suffered a stroke.
The incident, which regulators rated immediate jeopardy — the most serious classification short of death — centered on Resident 43, a woman admitted to the facility on March 4, 2025, with diagnoses that included cerebral infarction, depression, and anxiety. Her prescribed dose of Wellbutrin was 300 mg once daily. What she actually received: 300 mg every eight hours, three times a day, 900 mg total.
The error ran from the night of March 4 through the morning of March 8.
Nobody at the facility caught it. The family did.
R43's resident representative told inspectors he noticed within days of her admission that she seemed groggier and more sedated than normal. He flagged it to the facility's nurse practitioner, NP1, who told him the medications in the system were correct. NP1 gave him a copy of R43's current medication list. He took that list to R43's primary care physician and got a copy of her pre-admission medications. He compared them himself. That's when he found the discrepancy.
He called NP1 immediately. NP1 called poison control. Poison control told her to send R43 to the hospital for cardiac monitoring — excessive Wellbutrin raises the risk of cardiac arrhythmia. R43 spent several days at the hospital. When she came back, she was still confused, though improved. During her hospital stay, a CT scan revealed a cerebrovascular accident — a stroke. The hospital could not determine when it had occurred.
The medication error was not a data entry glitch. It was a process failure with multiple people who should have caught it and didn't.
Here's how the error happened, according to interviews with facility staff: When a resident is admitted, the pharmacy team enters the medication name and dose into the system as a draft order. The note left alongside contains the frequency, timing, and route. A floor nurse then reviews that draft and activates the order — manually entering the frequency, times, and route. That activation step is the critical human verification point. It's the last check before a drug goes to a patient.
The Director of Pharmacy Operations told inspectors the discharge instructions from the hospital were clear: Wellbutrin 300 mg once daily. The pharmacy entered the order correctly. What went wrong happened when LPN1 activated the draft.
LPN1 told inspectors she didn't remember the specific order, noting the incident happened in March and that she works only as needed. But she acknowledged that if the system showed her as the one who activated it, she likely did. She said she didn't pull orders "out of thin air" and must have gotten the frequency from somewhere — but couldn't explain how she arrived at every-eight-hours instead of once-daily.
The administrator's interview offers the most plausible explanation. The hospital discharge medication list had two drugs listed one above the other: Bupropion (Wellbutrin) 300 mg 24-hour extended-release tablet, once daily — and directly below it, Buspirone (Buspar) 10 mg tablet, three times daily. The names are similar. The dosing frequencies, stacked on a discharge sheet, may have blurred together. LPN1 appears to have applied the three-times-daily frequency from the Buspirone to the Bupropion.
The result: a woman with a history of cerebral infarction received 900 mg of an antidepressant that carries cardiac overdose risks, for five days straight, in a facility that didn't notice anything was wrong until her family intervened.
The Director of Nursing told inspectors LPN1 failed to follow protocol. Specifically, LPN1 activated the draft order without comparing it against R43's hospital discharge summary — the exact step the verification process exists to catch. The DON described the activation step as a "second check." It wasn't used as one.
NP1's account added another layer. She told inspectors she was in R43's room with the family trying to figure out why the resident was drowsy — and told the family she hadn't yet reviewed the MAR. She was still within her 72-hour medication reconciliation window. The family beat her to it.
"The process broke down when the nurse failed to verify the orders," NP1 told inspectors. She said LPN1 "failed at meeting her expectations regarding following safe procedure when inputting medication orders."
The medical director told inspectors R43 received Wellbutrin three times a day instead of once a day, and that the resident was sent to the hospital for three days of close monitoring. He attributed the error to the similarity between Bupropion and Buspirone — drugs with nearly identical names that appeared adjacent on the discharge sheet.
Inspectors classified the deficiency under F760, governing medication regimen review, at immediate jeopardy level, affecting few residents. The facility's own policy required the consulting pharmacist to contact a physician within one hour when a medication irregularity posed a risk to a resident's life, health, or safety. No such contact was documented before the family triggered the response.
There was also no order or documentation in R43's treatment record for antidepressant side effect monitoring — a gap that meant nobody was formally checking whether the drug was causing the sedation the family observed.
The facility submitted an immediate jeopardy removal plan on May 22, 2025, the day of the survey. It declared the facility had returned to compliance as of March 13, 2025 — five days after R43 was hospitalized.
The correction timeline, per facility records: March 8, R43 sent to the hospital. March 9, internal review revealed wrong dosage. March 12, incident reviewed with the medical director, pharmacy, and nursing staff; new admission procedure put in place; nurses re-educated; all current patient orders reviewed. March 13, facility declared compliant.
Going forward, the facility committed to requiring a second nurse to verify and activate all new admission medication orders — the step that was supposed to happen all along. The DON, ADON, or charge designee will now review all new admission orders after pharmacy and nurses enter them. Audits were scheduled daily for two weeks, weekly for eight weeks, then monthly until full compliance was documented. New hire orientation now includes medication admission training. Annual refreshers are required for all nurses.
The facility also said it would educate families about medication errors and incorporate family input into care plans.
That last item lands with some irony. In this case, it was the family — not the nurses, not the nurse practitioner, not the pharmacist, not the medical director — who found the error. R43's representative compared two medication lists himself, made the call, and set off the chain of events that got his family member to the hospital.
The facility is located at 200 Wellmore Drive in Lexington. The survey was completed May 22, 2025.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Retreat At Wellmore of Lexington from 2025-05-22 including all violations, facility responses, and corrective action plans.
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