Gettysburg Center: Nurse Gave Wrong Medication - PA
The incident occurred on July 31, 2025, at Gettysburg Center when Employee 1 approached Resident 1 with medication intended for another patient. Federal inspectors found that the nurse placed the syringe in the resident's mouth before she realized something was wrong and stopped him.
"I told him I don't take that medication," Resident 1 told inspectors during an August 13 interview. She said the nurse then left her room without explanation.
The resident experienced immediate physical effects from the morphine exposure. Her blood pressure dropped to 100/60 at 10:30 AM that morning, which she described as low for her. She also couldn't urinate for six to eight hours, which was unusual. Both symptoms are known side effects of morphine exposure.
Despite these concerning symptoms, no one from the facility approached Resident 1 about the incident. She wasn't sure if the male nurse had reported what happened.
The resident's daughter learned about the medication error only when her mother called that evening to tell her. During an August 13 interview, the daughter confirmed she received no notification from the facility about the incident involving her mother.
Employee 1 never reported the medication error to administrators. When the nursing home administrator was interviewed on August 13, she confirmed that Employee 1 had failed to report what happened with Resident 1.
The nurse provided a written statement on August 1 that failed to admit the syringe had entered the resident's mouth. The statement only acknowledged that he had approached Resident 1 and that she had stopped him.
By the time of the inspection, Employee 1 no longer worked at the facility.
The resident's physician was never notified about the morphine exposure, despite the patient experiencing documented side effects including low blood pressure and urinary retention.
Resident 1 told inspectors she was able to attend activities that day and had no complaints of discomfort, but the incident highlighted serious gaps in the facility's medication safety protocols and reporting procedures.
The inspection found that Gettysburg Center failed to ensure proper management oversight and resident care policies were followed. The facility's failure to report the medication error to the physician meant the resident received no medical evaluation or monitoring after being exposed to a narcotic pain medication not prescribed for her.
The morphine was intended for a different resident entirely, raising questions about how Employee 1 ended up in the wrong room with the wrong medication. The inspection report provides no details about medication verification procedures or how the mix-up occurred.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. However, the incident exposed systemic problems with medication administration and incident reporting at the 867 York Road facility.
The resident's daughter had to learn about her mother's medication exposure through a phone call from the resident herself, rather than through proper notification channels from the nursing home staff.
Resident 1's blood pressure reading of 100/60 and her inability to urinate for up to eight hours represented clear physiological responses to morphine exposure. Without physician notification, these symptoms went medically unevaluated.
The facility's administrator confirmed during the inspection that proper reporting protocols were not followed, and the nurse responsible for the error no longer works there.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Gettysburg Center from 2025-08-14 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
GETTYSBURG CENTER in GETTYSBURG, PA was cited for violations during a health inspection on August 14, 2025.
The incident occurred on July 31, 2025, at Gettysburg Center when Employee 1 approached Resident 1 with medication intended for another patient.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.