Magnolia Manor of Midway: Allergy Reaction After Wrong Drug - GA
The resident, identified in inspection records as R4, received three doses of Bactrim DS, a sulfa-based antibiotic, despite an allergy on file. A floor nurse spotted the reaction that morning and called the Director of Nursing. By then, the damage was done. A provider ordered IV fluids and Benadryl to treat the reaction. Staff monitored her vitals.
Federal inspectors from the Centers for Medicare and Medicaid Services cited Magnolia Manor of Midway for the incident following a complaint inspection completed October 9, 2025. The citation carried a finding of actual harm.
The nurse at the center of the incident, identified in the report as LPN AA, told inspectors that an allergy alert had appeared in the electronic medical record when she entered the prescription. She overrode it. Her explanation was that she believed both the unit manager and the doctor had already reviewed the resident's allergies. She did not call either of them to confirm. She also told inspectors she did not think the system would generate another alert after the first one had been dismissed. It did not. The medication kept coming.
She told inspectors she had received training on the six rights of medication administration, which includes verifying allergies before giving any drug. She said she did not remember R4 showing any symptoms after the first dose.
The Director of Nursing laid out how the breakdown compounded itself. A nurse should not relay telephone orders to another nurse, she told inspectors. Telephone orders have to be read back to the provider. Orders placed after hours should go through her directly, but because the provider had called the unit manager instead, that manager should have entered the order from home. None of that happened in the sequence the DON described as correct.
The DON also told inspectors she had no idea R4 was receiving Bactrim DS until the reaction appeared. She had not been called by the pharmacy. She was not aware of any allergy contraindication alert reaching the facility. She said allergy information is stored in the electronic record and entered at admission and during medication reconciliation. She had not contacted the pharmacy to request documentation of the interaction.
The administrator told inspectors that the electronic medical record had been updated to include additional alerts and that allergy information, along with diet and other precautions, was visible in the patient's chart ribbon. She was not certain whether that update happened before or after the incident involving R4. A new communication form had also been introduced to improve how staff relay information to providers. She said the pharmacy sends alerts through the electronic record and by fax, and that couriers delivering medications overnight also bring alerts that require staff signatures.
She said nurses had been educated on how to verify with a provider before completing an override. She expected that education to be finished, and said night shift staff still needed to receive it.
What the record shows is a chain of decisions, each one assuming someone else had already done the check. LPN AA assumed the unit manager and doctor had reviewed the allergies. She assumed the system would catch a second error after she had already cleared the first warning herself. The DON assumed the pharmacy would call if something was wrong. The pharmacy did not call. The unit manager did not enter the order. The override stood.
R4 received the drug three times before her skin told anyone something was wrong.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Magnolia Manor of Midway from 2025-10-09 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 24, 2026 · Our methodology
MAGNOLIA MANOR OF MIDWAY in MIDWAY, GA was cited for violations during a health inspection on October 9, 2025.
The resident, identified in inspection records as R4, received three doses of Bactrim DS, a sulfa-based antibiotic, despite an allergy on file.
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.