The same nurse administered insulin to another resident despite a discard-by date of July 15 stamped on the packaging. The inspection occurred August 19.
Federal inspectors calculated the facility's medication error rate at 18.52 percent, nearly four times the federal limit of 5 percent. The errors affected two of six residents whose medication administration was observed during the complaint investigation.
Licensed Practical Nurse E prepared both residents' medications on the morning of August 19. At 7:23 AM, the nurse prepared insulin for Resident 9, a Humalog vial that inspectors noted had no open date marked but carried the July discard date on its packaging. The nurse administered 6 units despite the expired medication.
Twenty-five minutes later, the same nurse prepared medications for Resident 32, who receives nutrition and medication through an enteral feeding tube. The nurse measured out medications including Linzess, acetaminophen, and a potassium chloride solution.
Inspectors watched the nurse pour the potassium solution into a separate cup, measuring 15 milliliters. The nurse mixed all medications with water, then used a 60-milliliter syringe to push the mixture through the resident's feeding tube.
The resident had tube feeding running at the time. The nurse stopped the feeding, disconnected it, and administered the medications without flushing the tube first.
When inspectors asked about post-medication flushing, the nurse explained that the resident receives preprogrammed flushes every four hours during tube feedings and wasn't due for a manual flush until 9:00 AM. The nurse returned at 9:01 AM to administer the water flush.
Facility policy requires flushing enteral tubes with at least 15 milliliters of water both before and after medication administration. The policy also mandates checking expiration dates before giving any medication.
Director of Nursing B confirmed these requirements during an interview at 10:02 AM, telling inspectors that tubes must be flushed before and after medications. She also stated that insulin vials should carry open dates and be discarded by the package date or 28 days after opening, whichever comes first.
Inspectors reviewed the physician orders and found Resident 32 was prescribed 3.75 milliliters of liquid potassium chloride, not the 15 milliliters administered.
At 1:09 PM, inspectors interviewed the nurse about the potassium dosage. The nurse acknowledged that Resident 32 should have received 3.75 milliliters per the order but was given 15 milliliters instead. The nurse immediately began the facility's medication error protocol.
The Director of Nursing was notified of the error at 1:20 PM and helped complete the error reporting process.
Potassium chloride requires precise dosing because excess amounts can cause dangerous heart rhythm abnormalities. The four-fold overdose represented a significant deviation from the prescribed treatment.
The medication errors occurred during routine morning administration, suggesting systemic problems with the facility's medication management rather than isolated incidents. Both errors involved different types of safety failures: expired medication use and incorrect dosing calculations.
Federal inspectors informed facility leadership of both medication errors at 3:35 PM on August 19. The following day at 12:51 PM, inspectors briefed Nursing Home Administrator A and the Director of Nursing on their findings from the medication administration observations.
The facility's 18.52 percent error rate means nearly one in five medication administrations contained mistakes during the inspection period. Federal research links medication errors to increased hospitalizations, adverse drug reactions, and preventable deaths in nursing homes.
The inspection classified the violations as causing minimal harm or potential for actual harm to residents. However, both the potassium overdose and expired insulin administration carried risks for serious complications.
Resident 32 continued receiving tube feedings and medications following the potassium error. The inspection report does not detail any immediate medical interventions or monitoring implemented after the overdose was discovered.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Wheaton Franciscan Hc - Terrace At St Francis from 2025-08-20 including all violations, facility responses, and corrective action plans.
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