Sterling Care Bel Air: Wrong Drug Given 34 Times - MD
The resident, diagnosed with mood disorder, depression and anxiety, was prescribed hydroxyzine for anxiety following a May 18 psychiatrist visit. Instead, nursing staff administered hydralazine, a blood pressure medication used to treat hypertension and heart failure.
The medication error began immediately after the psychiatrist's visit. A nurse's note from 9:15 PM on May 18 documented that the psychiatrist had ordered "Hydralazine 50 mg every 8 hours for anxiety for 14 days." The resident received the first dose of the wrong medication at 10:00 PM the following day.
For nearly two weeks, from May 19 through May 30, the resident received hydralazine every eight hours. Medication administration records show 34 total doses of the blood pressure drug were given for anxiety treatment.
The psychiatrist confirmed the error during an August 19 interview with federal inspectors. "The medication should have been hydroxyzine not hydralazine," the psychiatrist stated. Hydroxyzine is an antihistamine medication commonly prescribed to control anxiety symptoms.
The Director of Nursing acknowledged the mistake during the same day's inspection, confirming that Resident #5 received hydralazine instead of hydroxyzine throughout the 11-day period.
The drug mix-up represents a significant medication safety failure. Hydralazine works by relaxing blood vessels to lower blood pressure, while hydroxyzine blocks histamine receptors to reduce anxiety. Giving a blood pressure medication to treat psychiatric symptoms could potentially cause dangerous drops in blood pressure, particularly in elderly residents who may already have cardiovascular conditions.
Federal inspectors noted that the facility's psychiatry progress note from May 18 described the resident as "depressed very anxious" at the time the medication was prescribed. The resident had been admitted to Sterling Care Bel Air with multiple mental health diagnoses requiring careful psychiatric medication management.
The error went undetected for the entire prescribed treatment period. No documentation suggests that nursing staff, pharmacy personnel, or other clinical team members identified the inappropriate medication during routine safety checks or medication reviews.
Drug name confusion between hydralazine and hydroxyzine represents a known medication safety risk in healthcare settings. The similar spelling and pronunciation of the two drugs has led to mix-ups at facilities nationwide, prompting safety alerts from medication error reporting organizations.
Sterling Care Bel Air's failure occurred despite federal requirements that nursing homes maintain drug regimens free from unnecessary medications. The regulation is designed to protect residents from receiving drugs that provide no therapeutic benefit or could cause harm.
The facility's medication administration system failed to catch the error despite multiple opportunities for verification. Nurses typically review physician orders, pharmacists verify prescriptions, and additional staff may double-check medications before administration.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm. However, administering an inappropriate cardiac medication to treat anxiety symptoms could have resulted in serious complications, particularly given the resident's existing mental health conditions.
The inspection was conducted in response to a complaint, suggesting that concerns about medication safety or other care issues prompted the federal review. Inspectors reviewed nine residents' records during the complaint survey and identified the medication error affecting one resident.
No documentation indicates whether the facility conducted an internal investigation after discovering the error or implemented additional safeguards to prevent similar mix-ups. The inspection report does not specify when facility staff first became aware of the medication mistake.
The resident continued receiving the wrong medication until May 30, when the 14-day prescription period ended. Records do not indicate whether the resident experienced adverse effects from receiving blood pressure medication instead of anxiety treatment, or whether the intended psychiatric symptoms improved during the error period.
Sterling Care Bel Air operates on East McPhail Road in Bel Air, providing skilled nursing and rehabilitation services to residents with various medical and psychiatric conditions requiring specialized care and medication management.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sterling Care Bel Air from 2025-08-21 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
STERLING CARE BEL AIR in BEL AIR, MD was cited for violations during a health inspection on August 21, 2025.
The resident, diagnosed with mood disorder, depression and anxiety, was prescribed hydroxyzine for anxiety following a May 18 psychiatrist visit.
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.