Atlee Hill Health: Wrong Drug for Chest Pain - MD
The resident had a medical history of chest pain from unstable angina and a doctor's order for nitroglycerin tablets to be given sublingually every five minutes as needed for chest pain, up to three doses. Instead, staff administered Zofran, an antiemetic drug used to prevent nausea and vomiting.
The medication error came to light through complaint #337738, which alleged that staff failed to assess and properly medicate Resident #75 during a chest pain episode. Federal inspectors reviewed the case as part of their August 29, 2025 survey of the facility.
A nurse's note from October 19, 2024 documented the incident: "Reported from previous shift that Resident [complained] of chest pain through the night. She was given prn Zofran." The record showed no evidence that the resident received nitroglycerin despite the active physician's order.
Staff #10, a registered nurse, told inspectors during an August 28 interview that she received a report on the morning of October 19 from the outgoing nurse. The previous shift nurse had informed her that Resident #75 complained of chest pain during the night and was given an antiemetic drug.
The facility's Director of Nursing acknowledged the error during an interview the following day. She confirmed that Resident #75 had an attending provider's order for medication specifically for chest pain. She told inspectors she expected her staff to give the resident the prescribed angina medicine when chest pain was reported, not an antiemetic drug.
Nitroglycerin is a standard treatment for angina attacks, working by dilating blood vessels to improve blood flow to the heart muscle. The sublingual tablets are designed for rapid absorption under the tongue during acute chest pain episodes. Zofran, by contrast, is an anti-nausea medication with no cardiac benefits.
The inspection report classified the violation as causing minimal harm or potential for actual harm to residents. Federal regulations require that each resident's drug regimen be free from unnecessary drugs and that prescribed medications be administered according to physician orders.
The case represents one of five complaints reviewed during the federal survey, with inspectors determining that staff failed to follow proper medication administration protocols in this instance. The facility's medication management systems failed to ensure the resident received appropriate cardiac treatment during a potentially serious episode.
For residents with unstable angina, prompt administration of prescribed nitroglycerin can be critical during chest pain episodes. The medication helps prevent the progression of symptoms that could lead to more serious cardiac events requiring emergency intervention.
The Director of Nursing's acknowledgment that staff should have administered the prescribed angina medication highlights the gap between established protocols and actual practice. Despite having clear physician orders for cardiac medication, nursing staff opted for an unrelated drug that provided no therapeutic benefit for the resident's chest pain complaint.
Federal inspectors noted that few residents were affected by the medication administration deficiency, but the case illustrates broader concerns about staff training and protocol adherence in emergency situations. The facility must now develop and implement corrective measures to prevent similar medication errors.
The inspection found that nursing staff failed to properly assess the resident's complaint and match the appropriate medication to the documented symptoms. This represents a fundamental breakdown in the medication administration process that nursing homes are required to maintain under federal regulations.
Resident #75's experience demonstrates how medication errors can occur even when proper orders exist and staff are aware of a resident's medical history. The case underscores the importance of staff training on recognizing cardiac symptoms and administering appropriate emergency medications according to physician orders.
The facility has not yet submitted its plan of correction for the medication administration deficiency identified during the August inspection.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Atlee Hill Health and Rehab Center from 2025-08-29 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
ATLEE HILL HEALTH AND REHAB CENTER in WESTMINSTER, MD was cited for violations during a health inspection on August 29, 2025.
Instead, staff administered Zofran, an antiemetic drug used to prevent nausea and vomiting.
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.