Country Club Center: Heart Medication Errors - OH
Country Club Center V admitted Resident #24 in October with multiple heart conditions including paroxysmal atrial fibrillation and hypertension. The resident was severely cognitively impaired and required careful monitoring of a powerful heart medication called Amiodarone.
The medication problems began in August when a nurse spoke with an on-call physician about the resident's Amiodarone dosage. The doctor ordered staff to check the resident's blood pressure and heart rate twice daily for 14 days and to hold the medication if the heart rate dropped below 50 beats per minute.
But staff never followed the monitoring orders.
Records from August 10 through August 24 show nursing staff checked the resident's blood pressure and heart rate only once daily instead of twice as ordered. The facility's own blood pressure and pulse summaries confirmed the single daily checks continued through August 28.
On August 20, the resident's heart rate dropped to 49 beats per minute. Staff properly held the Amiodarone medication. Three days later, the heart rate fell even lower to 45 beats per minute, and staff again held the medication.
The physician's orders specifically required staff to notify the cardiologist whenever the medication was held. But progress notes from both August 20 and August 23 contain no documentation that anyone contacted the heart specialist about the dangerously low heart rates.
Licensed Practical Nurse #139 confirmed during an inspection interview that she received the August 10 order requiring twice-daily vital sign checks for 14 days. She acknowledged that the medical record showed no evidence the cardiologist was notified when the Amiodarone was held on either date.
The nurse explained that she had made an error when entering the monitoring order into the facility's computer system. She selected "other orders no documentation required" instead of the correct order type, which prevented the vital sign checks from appearing on the medication administration record or treatment administration record where nursing staff would see them.
"LPN #139 confirmed vital signs were not completed," according to the inspection report.
Director of Nursing also confirmed during an August 27 interview that the medical record contained no evidence physicians were notified about the held medication doses. She acknowledged that blood pressure and heart rate measurements were not taken twice daily as ordered during the two-week monitoring period.
Amiodarone is a potent medication used to control irregular heartbeats in patients with atrial fibrillation. The drug can cause the heart rate to slow dramatically, which is why physicians ordered such careful monitoring. When heart rates drop too low, patients can experience dizziness, fainting, or more serious complications.
The resident's care plan from November specifically identified the potential for cardiac symptoms related to atrial fibrillation and hypertension. Planned interventions included administering medications as ordered, following up with the cardiologist as ordered, and observing for side effects.
Federal inspectors found the facility failed to ensure staff implemented physician orders and monitored vital signs as required. The violation affected one resident out of three records reviewed for following physician orders.
The missed monitoring occurred during a critical period when the resident's medication dosage was being adjusted. In mid-August, physicians reduced the Amiodarone dose from 200 milligrams to 100 milligrams daily and changed the parameters for holding the medication from heart rates below 60 beats per minute to below 50 beats per minute.
Despite the revised orders and lower threshold, staff continued the pattern of inadequate monitoring and communication failures.
The facility houses 44 residents and was cited for failing to ensure each resident's drug regimen remained free from unnecessary drugs. Inspectors classified the violation as causing minimal harm or potential for actual harm.
Country Club Center's monitoring failures left physicians without crucial information about how the resident was responding to the heart medication. The cardiologist remained unaware that the medication had been held twice in four days due to concerning heart rates, preventing any necessary adjustments to the treatment plan.
The computer system error that prevented monitoring orders from appearing on staff schedules highlights broader problems with medication management protocols at the facility. When critical safety orders disappear from daily workflows, residents face increased risks from unmonitored medications.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Country Club Center V, Inc from 2025-08-28 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
COUNTRY CLUB CENTER V, INC in DELAWARE, OH was cited for violations during a health inspection on August 28, 2025.
Country Club Center V admitted Resident #24 in October with multiple heart conditions including paroxysmal atrial fibrillation and hypertension.
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.