Greenwood Center: Wrong Dementia Drugs Given - RI

The mix-up occurred on the evening of August 12 at Greenwood Center when Staff A administered Donepezil, Namenda, Senna tablets, and Plavix to the wrong resident. Someone reported the incident to state health officials the next day.

Resident ID #1, who has severe cognitive impairment and chronic kidney disease, received medications meant for Resident ID #2. The drugs included Donepezil and Namenda, both prescribed to treat Alzheimer's disease, along with Senna laxative tablets and Plavix, a blood thinner used to prevent clots.

None of these medications appeared on Resident ID #1's medication administration record. The resident's actual diagnoses include chronic kidney disease, anemia, high blood pressure, and unspecified dementia with anxiety.

A mental status assessment revealed Resident ID #1 scored 4 out of 15 points, indicating severe cognitive impairment. The resident had lived at the facility since September 2021.

The error began when Registered Nurse Staff B prepared the evening medications and handed them to the medication technician. Staff B told inspectors she gave Staff A a cup containing the four medications with instructions to give them to "the resident in the bed by the window."

Staff A administered the drugs to the resident in the bed by the door instead.

Registered Nurse Staff B documented the incident in a progress note at 2:03 AM on August 13. She wrote that Staff A had given Resident ID #1 the evening medications intended for the roommate. The resident's medical provider was contacted immediately and recommended monitoring for 72 hours.

During interviews with state inspectors on August 14, Staff B confirmed the sequence of events. She explained that after the medication technician administered the drugs, Staff A realized the mistake and reported giving the medications to the wrong resident.

The Director of Nurses acknowledged to inspectors that Resident ID #1 had received unnecessary medications on August 12.

Medication administration records showed that Resident ID #2's prescribed evening doses were all signed off as administered on August 12. The roommate's medication regimen included Donepezil 10 mg once daily at 4:00 PM, Namenda 10 mg once daily at 4:00 PM, and Plavix 75 mg once daily at 4:00 PM.

The complaint submitted to the Rhode Island Department of Health on August 13 specifically alleged that the medication technician had administered drugs prescribed to one resident's roommate. State inspectors confirmed this allegation during their investigation.

Federal regulations require nursing homes to ensure each resident's drug regimen remains free from unnecessary medications. Inspectors determined Greenwood Center failed to meet this standard for Resident ID #1.

The incident involved medications with significant effects. Donepezil and Namenda are specifically designed to slow cognitive decline in Alzheimer's patients. Plavix prevents blood clots but can increase bleeding risk, particularly concerning for someone with kidney disease like Resident ID #1.

Inspectors classified the violation as causing minimal harm or potential for actual harm. The finding affected few residents, according to the inspection report.

The medication mix-up occurred despite standard procedures requiring staff to verify patient identity before drug administration. The confusion between "bed by the window" and "bed by the door" suggests problems with the facility's patient identification system.

Staff B's decision to contact the medical provider immediately and implement 72-hour monitoring showed appropriate response to the error. However, the incident raised questions about medication preparation and distribution procedures at the 4:00 PM shift change.

The complaint reached state health officials within hours of the incident, indicating either family members or staff reported the medication error quickly. This rapid reporting allowed inspectors to investigate while the incident remained fresh in staff memory.

Greenwood Center must now submit a plan of correction to continue participating in federal health programs. The facility has 14 days from receiving the inspection report to make their response publicly available.

The 72-hour monitoring period for Resident ID #1 reflected medical concerns about drug interactions and potential adverse effects from receiving medications not prescribed for their specific conditions and diagnoses.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Greenwood Operations Dba Greenwood Center from 2025-08-14 including all violations, facility responses, and corrective action plans.

Additional Resources

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