The medication mix-up at Care One at Newton involved methotrexate, a drug used to treat autoimmune conditions that can cause serious side effects when given incorrectly. The resident was supposed to receive the medication once weekly according to hospital discharge instructions. Instead, staff entered an order for twice-daily administration.
Physician #1 signed the dangerous order electronically on July 28, six days after a nurse initially entered it into the system.
The resident had been admitted in July with antiphospholipid syndrome, an autoimmune condition that causes blood clots, and CREST syndrome, a form of systemic sclerosis. Hospital discharge instructions clearly specified methotrexate 2.5 milligram tablets, 10 tablets by mouth every seven days — five in the morning and five in the evening.
But Nurse #1 entered a different order on July 22: methotrexate 2.5 milligrams, give five tablets by mouth two times a day.
When inspectors interviewed the physician by phone on September 4, he said he was in the facility when the resident was admitted and had reviewed the hospital discharge summary. He said all medications listed were to be continued at the facility.
"Physician #1 said he was very familiar with Methotrexate and that it was administered weekly," inspectors wrote.
Yet he signed the twice-daily order anyway.
The physician explained that orders come to him electronically, often in bulk. He receives 150 to 200 orders at a time, he told inspectors.
A nurse practitioner compounded the documentation problems. NP #1 visited the resident on July 23 and July 28, documenting in progress notes both times that the resident's methotrexate order was "take 5 tablets by mouth everyday two times per day."
When inspectors called the nurse practitioner on September 4, he said that although he listed all the resident's medications in his progress notes, he only reviewed medications "pertinent to his visits."
Methotrexate was managed by specialists, he said, and he wasn't familiar enough with the recommended frequency to question the order directions.
The facility's own policies required complete and accurate documentation. A 2017 policy on charting stated that documentation "will be objective, complete, and accurate." It also required that electronic entries that are auto-filled or auto-prompted "must be reviewed and updated when more current information is available."
A 2016 medication policy required that orders "will be consistent with principles of safe and effective order writing."
The Medical Director told inspectors by phone on September 4 that he expected providers to catch mistakes like the methotrexate order. All medical record entries "must be right," he said.
The Director of Nurses echoed that expectation during a September 9 phone interview, saying he expected all medical record entries to be complete and accurate.
Federal inspectors found the facility failed to ensure the resident's medical record was complete and accurate on two counts: the physician signing a medication order in error, and the nurse practitioner documenting that all medications were reviewed at each visit when he admitted he only reviewed some.
The inspection was triggered by a complaint and completed September 3. Inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents.
Methotrexate is commonly used to treat rheumatoid arthritis and other autoimmune conditions, but requires careful monitoring due to potential side effects including liver damage, lung problems, and increased infection risk. The difference between weekly and daily dosing represents a seven-fold increase in drug exposure.
The resident's complex medical conditions — antiphospholipid syndrome and CREST syndrome — already required careful medication management to prevent blood clots and manage autoimmune symptoms.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Care One At Newton from 2025-09-03 including all violations, facility responses, and corrective action plans.