Gettysburg Center: Nurse Used Same Syringe on Two - PA
The incident occurred July 31 when the nurse entered a room where a woman lived with her hospice-status husband. The resident was asleep when the nurse placed the syringe in the corner of her mouth.
"No, no, no that is my husband's medication," the woman said immediately after waking up. She told investigators she could taste some of the morphine before the syringe was removed.
The nurse then turned around and inserted the same syringe into the husband's mouth to administer his prescribed medication.
The woman reported the incident to nursing staff five hours later at 7 AM and called her daughter that evening to tell her what happened.
Federal inspectors found the facility violated infection control standards by allowing the contaminated syringe to be reused. Centers for Disease Control guidelines state that single-dose syringes should never be used for more than one patient.
The contamination risk was heightened because the first resident was receiving antibiotic treatment for bacterial sinusitis. Her medical records showed she had been prescribed Cefuroxime Axetil 500 milligrams twice daily for seven days, starting July 29 — just two days before the syringe incident.
During interviews with federal investigators in August, the resident's daughter expressed concern about the cross-contamination between her parents. She said facility staff never notified her about the medication error and she only learned of it when her mother called that evening.
The resident involved has intact mental capacity, scoring 15 on a standardized cognitive assessment completed in May. She was admitted to Gettysburg Center with diagnoses including high blood pressure and difficulty swallowing.
Facility policy requires staff to record incidents under the infection prevention and control program and document corrective actions taken. The policy specifically identifies reusing single-dose syringes as a "breach in practice" that constitutes failure in infection control.
The nursing home administrator acknowledged during the August inspection that the syringe should have been discarded after being placed in the first resident's mouth. The administrator also confirmed that the incident should have been reported by the nurse involved.
The registered nurse who committed the violation no longer works at the facility.
Federal regulations mandate that nursing homes maintain professional practices supporting infection prevention and control. The facility's own policy, last revised in February, states that centers must record incidents and breaches in practice, including non-compliance with infection control standards.
The inspection found the facility failed to maintain proper infection control practices for this resident. Investigators noted that reports from staff, patients, or families regarding healthcare-associated infections or disease spread due to infection control errors must be documented and addressed.
The woman's daughter told inspectors she was never officially notified about the medication error by facility staff, learning of it only through her mother's phone call hours after the incident occurred.
The contaminated syringe incident represents a fundamental breakdown in basic infection control protocols. Using the same syringe on two patients violates core medical safety standards designed to prevent cross-contamination and potential transmission of infections between residents.
The timing of the error — occurring at 2 AM when staffing levels are typically reduced — raises questions about overnight medication administration procedures at the facility. The resident's immediate recognition that the medication wasn't intended for her suggests the nurse may have been administering medications without proper patient identification protocols.
The fact that one resident was actively being treated for a bacterial infection when the cross-contamination occurred compounds the severity of the breach. Bacterial sinusitis, while treatable with antibiotics, could potentially spread to other vulnerable nursing home residents through contaminated medical equipment.
The facility's failure to notify the resident's family about the medication error violated their own policies requiring incident reporting. The daughter's concern about cross-contamination between her parents reflects the real risks posed when infection control standards break down in congregate care settings.
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 15, 2026 · Our methodology
GETTYSBURG CENTER in GETTYSBURG, PA was cited for violations during a health inspection on August 14, 2025.
The incident occurred July 31 when the nurse entered a room where a woman lived with her hospice-status husband.
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.
Frequently Asked Questions
- What happened at GETTYSBURG CENTER?
- The incident occurred July 31 when the nurse entered a room where a woman lived with her hospice-status husband.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in GETTYSBURG, PA, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from GETTYSBURG CENTER or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 395733.
- Has this facility had violations before?
- To check GETTYSBURG CENTER's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.