The medication error occurred during evening rounds on September 9, 2025. Licensed nurse Employee E3 entered the veteran's room where two other residents were visiting and called out the patient's last name. When someone answered "Yes," the nurse proceeded to administer medications intended for a different patient entirely.
The veteran became pale and nauseous shortly after receiving the wrong medications. They vomited after eating just a few bites of dinner. Staff recorded vital signs showing a heart rate of 56 beats per minute and blood pressure of 122/60. The facility physician ordered an immediate hospital transfer.
Hospital records revealed the veteran was admitted with lightheadedness, nausea, vomiting and "ingestion of unknown medications." The admission diagnosis was medication side effects and near syncope. The veteran suffered transient bradycardia — a temporary but dangerous drop in heart rate — likely caused by Diltiazem, a heart medication they should never have received.
The veteran remained hospitalized from September 9 through September 12, requiring intravenous fluids and treatment for constipation caused by the medication error.
Employee E3 discovered the mistake only when preparing to give medications to the intended recipient and realizing those drugs had already been administered to the wrong patient. In a written statement dated September 9, the nurse explained that the veteran "was laughing and talking with the other two residents, that they must not have heard" when their name was called.
The nurse was not the veteran's regular caregiver, according to the Director of Nursing interviewed during the October 7 inspection.
This marked the latest in a pattern of medication safety failures at the facility. State inspectors had previously cited Southeastern Pennsylvania Veteran's Center for similar nursing service violations on July 1, May 9, June 14, and March 16 of 2025.
The facility completed an internal investigation the same day as the error. Their corrective action plan included mandatory medication competency testing for the nurse involved and updating resident photographs for those who had lived at the facility longer than one year.
Management also implemented name bands for all residents and required medication competency testing for all licensed staff before their first medication pass. This included PRN staff, those on light duty, and nurses returning from family medical leave.
The Assistant Director of Nursing was tasked with auditing five random residents' medication administration weekly for three months, with findings reported to monthly Quality Assurance meetings.
State inspectors verified completion of these corrective measures during their October 7 visit through medication administration observations, review of training records, recorded audits, and staff interviews. The facility had completed its plan of correction by September 15.
The inspection findings were conveyed to both the facility Commandant and Director of Nursing on October 7 at 2:00 p.m.
Federal inspectors determined the facility "failed to ensure Resident 1 was free from a significant medication error, which resulted in the harm of being hospitalized due to the medication side effects."
The veteran's three-day hospitalization could have been prevented if the nurse had properly identified the patient before administering medications — a basic safety protocol that failed when the caregiver relied on a verbal response in a room with multiple residents present.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Southeastern Pennsylvania Veteran's Center from 2025-10-07 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Southeastern Pennsylvania Veteran's Center
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