Edgewood Manor: Double-Dose Blood Pressure Error - OH
Edgewood Manor of Wellston staff gave Resident #39 one full 25-milligram tablet of metoprolol twice daily instead of the prescribed half-tablet dose, federal inspectors found during a September complaint investigation. The error meant the resident received 50 milligrams daily rather than the intended 25 milligrams.
The resident had been admitted to the facility in late July with diagnoses including hypertension, diabetes mellitus, and adult failure to thrive. An August assessment documented impaired cognition.
Hospital discharge instructions from July 30 clearly specified the resident should continue taking "one half of a tablet of 25 milligram metoprolol twice a day" after leaving the hospital. But when facility staff wrote the physician's order the next day, they documented "one whole tablet of 25 mg metoprolol to be administered twice a day."
The Director of Nursing confirmed the transcription error during an interview with inspectors on September 4. She acknowledged that while hospital discharge instructions called for 12.5 milligrams twice daily, the facility order specified 25 milligrams twice daily.
Metoprolol is an anti-hypertensive medication used to treat high blood pressure and other heart conditions. Dosing errors with blood pressure medications can cause dangerous drops in blood pressure, dizziness, falls, or other cardiovascular complications, particularly in elderly residents with multiple medical conditions.
The medication error affected one of 16 residents whose medications inspectors reviewed at the 40-bed facility. Records showed no documented adverse effects from the doubled dose, though such effects might not always be immediately apparent or properly documented.
The investigation stemmed from two separate complaints filed against the facility. Inspectors cited Edgewood Manor for failing to ensure discharge medication orders were accurately implemented, a violation of federal requirements that facilities provide appropriate pharmaceutical services to meet each resident's needs.
For Resident #39, the combination of impaired cognition, multiple chronic conditions, and the medication error created particular vulnerability. Cognitively impaired residents may be less able to recognize or report symptoms from medication problems, making accurate dosing and careful monitoring especially critical.
The transcription error persisted from July 31 through the September inspection, meaning the resident received the incorrect dose for more than a month. During this period, staff administered exactly what the facility's order specified, but that order itself was wrong from the beginning.
Federal regulations require nursing homes to employ or obtain services from licensed pharmacists and ensure pharmaceutical services meet each resident's needs. The regulations also mandate that facilities accurately implement physician orders and hospital discharge instructions.
This type of medication transcription error represents a fundamental breakdown in the medication management process. When residents transfer from hospitals to nursing homes, accurate communication of medication orders becomes crucial for continuity of care.
The facility's violation was classified as causing "minimal harm or potential for actual harm" affecting "few" residents. However, medication errors involving blood pressure medications can have serious consequences, particularly for elderly residents with multiple health conditions.
Resident #39's case illustrates how seemingly simple administrative tasks like transcribing medication orders can have significant clinical implications. The doubling of a blood pressure medication dose, even without documented adverse effects, represents a serious departure from prescribed care.
The error also highlights the vulnerability of cognitively impaired nursing home residents, who depend entirely on facility staff to manage their medications correctly. These residents cannot advocate for themselves or question medication changes, making accurate order transcription and implementation essential for their safety.
Edgewood Manor must now submit a plan of correction addressing how it will prevent similar medication transcription errors in the future. The facility will need to demonstrate improved processes for accurately implementing hospital discharge medication orders.
The September inspection was triggered by complaints, suggesting ongoing concerns about care quality at the facility. Federal inspectors found this medication error while investigating two separate complaint cases, indicating potential systemic issues with medication management.
For Resident #39, the medication error meant receiving double the intended blood pressure medication dose throughout their stay, a situation that could have been prevented with careful attention to hospital discharge instructions.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Edgewood Manor of Wellston from 2025-09-04 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
EDGEWOOD MANOR OF WELLSTON in WELLSTON, OH was cited for violations during a health inspection on September 4, 2025.
The error meant the resident received 50 milligrams daily rather than the intended 25 milligrams.
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.