Laredo West Nursing: 10x Overdose Error - TX
The overdose happened on April 27 when RN A administered 5 milliliters instead of the prescribed 0.5 milliliters. Nobody discovered the error until shift change more than 10 hours later, when nurses were counting controlled substances at 10:24 p.m.
The attending physician ordered immediate administration of Narcan, a drug used to reverse opioid and sedative overdoses. Staff were instructed to monitor the resident's neurological status and vital signs every hour for the next 24 hours.
RN A wrote in an incident report the next day: "RN A gave scheduled medication- Lorazepam 0.5ml, but I accidentally gave 5ml. Discovery of medication error was made during change of shift medication count."
The mistake violated multiple steps in the facility's medication administration policy. Nurses are required to compare the medication source with the medication administration record to verify the correct dose before giving any drug. They must also review the record to identify what medication should be administered.
Federal inspectors cited Laredo West Nursing and Rehabilitation Center for immediate jeopardy to resident health and safety. The designation is reserved for violations that could cause serious injury, harm, impairment or death.
Lorazepam belongs to a class of drugs called benzodiazepines, which slow down the central nervous system. An overdose can cause extreme drowsiness, confusion, muscle weakness, and potentially fatal respiratory depression, especially in elderly residents who may already have compromised breathing or heart function.
The facility's director of nursing conducted a performance review of RN A on May 28. The review stated no medication errors occurred during that period, suggesting the nurse had improved following additional training and supervision.
But the April incident triggered immediate corrective measures. The assistant director of nursing provided one-on-one training to RN A on April 28 at 2:30 p.m., focusing on medication administration policies and procedures.
RN A signed a document acknowledging several commitments: "I will be getting a second license nurse to verify dosage administered with every Narcotic given for 4 weeks. When in doubt, I will ask a co-worker, ADON, or DON for assistance in completing task. I will verify all information before documenting on PCC."
The director of nursing also mandated that another nurse witness RN A's administration of all controlled substances for 30 days. The administrator signed off on this supervision plan.
The facility conducted facility-wide medication training on April 28. Twenty-five of 26 registered nurses and licensed vocational nurses attended.
The nursing home's medication policy, last updated in October 2022, requires multiple verification steps that should have prevented the overdose. Nurses must identify residents using photos in medication records. They must compare medication containers with administration records to verify resident name, medication name, form, dose, route and timing.
Staff are supposed to administer medications exactly as ordered and sign the medication record immediately afterward. For controlled substances like lorazepam, they must also sign a separate narcotic log book.
The policy requires nurses to report and document any adverse effects or medication refusals, and to correct discrepancies immediately while reporting them to the nurse manager.
None of these safeguards caught RN A's error before the resident received 10 times the intended dose.
The incident report shows the oversight system ultimately worked through the shift-change medication count, a standard practice where incoming and outgoing nurses verify controlled substance inventories. But by then, the resident had already received a potentially dangerous overdose and gone hours without appropriate monitoring.
The inspection report does not indicate whether the resident suffered lasting harm from the medication error or how they responded to the emergency treatment with Narcan.
Federal regulators found the facility's response inadequate to prevent similar incidents, leading to the immediate jeopardy citation. The designation requires nursing homes to submit detailed correction plans and undergo follow-up inspections to verify improvements in medication safety protocols.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Laredo West Nursing and Rehabilitation 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 19, 2026 · Our methodology
Laredo West Nursing and Rehabilitation Center in Laredo, TX was cited for violations during a health inspection on August 14, 2025.
The overdose happened on April 27 when RN A administered 5 milliliters instead of the prescribed 0.5 milliliters.
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.