LEXINGTON, SC - A medication reconciliation failure at Wellmore of Lexington resulted in a resident receiving three times the prescribed dose of an antidepressant, leading to hospitalization for cardiac monitoring.
Dangerous Dosing Error Discovered by Family
The incident occurred in March 2025 when a newly admitted resident received Wellbutrin (bupropion) 300mg every eight hours instead of the prescribed once-daily dose. The resident's family noticed increased drowsiness and grogginess in the days following admission and reported their concerns to the facility's nurse practitioner.
According to the inspection report, the family obtained the resident's medication list from the nursing home and compared it to the prescription list from their primary care provider. This comparison revealed the significant dosing discrepancy that facility staff had missed during the admission process.
The resident's representative stated: "Over the following days the family noticed that [the resident] was more groggy and sleepier than normal... After comparing the two-medication lists, [we] discovered that there was a discrepancy in [the resident's] Wellbutrin dose."
Medical Implications of Antidepressant Overdose
Bupropion overdose can cause serious cardiac complications, seizures, and altered mental status. The medication affects neurotransmitter levels in the brain and, when given in excessive doses, can lead to dangerous side effects including cardiac arrhythmias and central nervous system toxicity.
When the error was discovered, the nurse practitioner immediately contacted poison control, which recommended hospital evaluation and monitoring. The resident spent three days in the hospital under cardiac observation due to the overdose risk.
System Breakdown in Medication Reconciliation
The error occurred during the facility's medication reconciliation process, which involves multiple safety checkpoints designed to prevent exactly this type of mistake. Hospital discharge records showed the resident should receive Wellbutrin 300mg once daily, but the order was incorrectly entered as every eight hours.
The Director of Pharmacy Operations confirmed that pharmacy staff correctly entered the medication as once daily based on hospital discharge instructions. However, when the floor nurse activated the order in the facility's system, the frequency was changed to every eight hours.
The facility's Medical Director noted that the error may have stemmed from confusion between two similarly named medications on the discharge summary. The document listed bupropion (Wellbutrin) 300mg daily directly above buspirone (Buspar) 10mg three times daily, potentially leading to dosing confusion.
Immediate Jeopardy Violations
Federal inspectors cited the facility for immediate jeopardy violations, the most serious category of nursing home deficiencies. This designation indicates conditions that pose an immediate threat to resident health and safety.
The Licensed Practical Nurse involved in the medication entry stated: "If the system states that she was the one who input the order on the resident chart, then it was possible that she may have put in the incorrect order."
The facility's Director of Nursing acknowledged that proper protocols were not followed, stating that the nurse "did not follow protocol when reviewing [the resident's] Wellbutrin order on draft" and activated the medication without proper verification.
Corrective Actions and Process Changes
Following the incident, Wellmore implemented several systemic changes to prevent similar errors:
- Enhanced verification process: A second nurse now verifies all medication orders before activation - Leadership oversight: The Director of Nursing or designee reviews all new admission medication orders - Staff re-education: All nursing staff received refresher training on medication reconciliation procedures - Increased auditing: Daily audits of new medication orders for initial weeks, followed by weekly and monthly reviews
The facility also implemented family education programs about medication safety and incorporated family input into care planning to enhance error prevention.
Regulatory Response and Compliance
The facility provided an acceptable immediate jeopardy removal plan and achieved full compliance by March 13, 2025. However, the incident highlights critical weaknesses in medication safety systems that nursing homes rely upon to protect vulnerable residents.
Medication errors in nursing homes can have devastating consequences, particularly for residents taking medications with narrow therapeutic windows like antidepressants. The multi-step verification process exists specifically to catch errors before they reach residents, making system failures like this particularly concerning.
The resident's mental status improved after the medication was corrected, though the hospitalization revealed an additional complication - a cerebrovascular accident of unknown timing that may have contributed to confusion upon readmission.
This case demonstrates the importance of family involvement in monitoring loved ones' care and the critical need for robust medication reconciliation systems in long-term care facilities.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Wellmore of Lexington, LLC from 2025-05-22 including all violations, facility responses, and corrective action plans.
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