Registered Nurse #100 prepared the wrong dose and wrong type of several medications for Resident #15 on October 29, then walked to her table without the diuretic and aspirin she takes daily. Only when she looked in the medication cup and asked "where her Bumex and aspirin were" did the nurse return to his cart.
The nurse had given her one tablet of the antipsychotic Fluphenazine instead of the two tablets ordered by her physician. He also prepared an enteric-coated aspirin instead of the chewable tablet prescribed for the resident, who has chronic obstructive pulmonary disease and major depressive disorder alongside her schizoaffective condition.
Federal inspectors observed 27 medication administration opportunities during their complaint investigation and found three errors affecting the single resident they monitored. The 11.11 percent error rate far exceeds the 5 percent threshold that triggers federal violations.
The resident had been living at the 107-bed facility since May 30. Her quarterly assessment showed she was cognitively intact and required supervision with eating, bed mobility, toileting and transfers.
At 10:19 that morning, inspectors watched Nurse #100 prepare her medications. He placed one 10-milligram Fluphenazine tablet in the medication cup along with Hydroxyzine for allergies, Metoprolol for blood pressure, Lamotrigine for bipolar disorder, Trihexyphenidyl for tremors, turmeric supplement, stress formula vitamin, Sennosides for constipation, Lorazepam for anxiety, and Geodon, another antipsychotic.
Her physician had ordered two Fluphenazine tablets twice daily since August 19. She was also supposed to receive Bumetanide, a diuretic, and 81-milligram chewable aspirin daily under orders written when she was admitted in May.
Ten minutes later, the nurse carried the medication cup to where Resident #15 sat at a table. She examined the pills and immediately noticed the missing medications.
The nurse returned to his electronic medical record, reviewed her medication list, then opened his drawer to retrieve the Bumetanide card and a bottle of aspirin. But he grabbed enteric-coated aspirin pills instead of the chewable tablets ordered for her.
When inspectors interviewed him at 10:27, Nurse #100 acknowledged he had prepared only one Fluphenazine tablet instead of two. He also admitted giving enteric-coated aspirin rather than the chewable form prescribed by her doctor.
The nurse confirmed he had not prepared the Bumetanide and aspirin until after Resident #15 told him they were missing from her medication cup.
The facility's medication error rate of 11.11 percent represents more than double the federal threshold. Research shows medication errors in nursing homes can cause serious harm to residents, particularly those with complex conditions requiring multiple daily medications.
Resident #15's combination of mental health conditions and physical ailments requires precise medication management. Schizoaffective disorder involves both schizophrenia symptoms and mood disorders, making consistent antipsychotic dosing critical for stability.
The resident's cognitive awareness allowed her to catch the nurse's mistakes. Had she been less alert or more confused, she might have gone without essential medications or received incorrect doses without anyone noticing.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm. The investigation stemmed from a complaint filed against the facility.
The errors occurred despite electronic medical records that should have guided proper medication preparation. The nurse had access to the resident's complete medication list but failed to follow the physician orders for correct dosing and formulation.
Bumetanide helps prevent fluid buildup in patients with heart or lung conditions. Missing this diuretic could worsen breathing problems for someone with chronic obstructive pulmonary disease.
The difference between chewable and enteric-coated aspirin matters for absorption and effectiveness. Chewable tablets dissolve faster and may be easier for some residents to take, particularly those with swallowing difficulties.
The facility census of 107 residents means the medication errors affected nearly one percent of the population during the limited observation period. Extrapolated across daily medication passes, the error rate suggests dozens of residents could receive incorrect medications regularly.
Nurse #100's acknowledgment of his mistakes indicates awareness of proper procedures. Yet he failed to follow physician orders for dosing and medication type, then forgot two medications entirely until the resident questioned their absence.
The resident's ability to advocate for herself prevented potentially serious consequences from missing her diuretic and receiving inadequate antipsychotic medication.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Harmony Court Rehab and Nursing from 2025-10-30 including all violations, facility responses, and corrective action plans.
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