The medication errors at Harmony Court Rehab and Nursing affected a resident with schizoaffective disorder who had been living at the facility since May. Federal inspectors documented the violations during an October complaint investigation at the 107-bed facility.
Resident #15 required multiple psychiatric medications, including Fluphenazine for her schizoaffective disorder and Geodon, another antipsychotic. Her physician had ordered two 10-milligram tablets of Fluphenazine twice daily starting in August.
On October 29, inspectors watched Registered Nurse #100 prepare the morning medications. He placed one Fluphenazine tablet into the medication cup instead of two. He also prepared nine other medications, including drugs for high blood pressure, anxiety, and constipation.
The nurse took the medication cup to the table where the resident sat waiting.
She looked into the cup and asked where her Bumex and aspirin were.
The nurse returned to his medication cart and opened the electronic medical record. After reviewing the orders, he retrieved a Bumex tablet from the medication drawer and grabbed an 81-milligram enteric-coated aspirin from a bottle. He delivered the additional pills to the resident.
But he had given her the wrong type of aspirin. Her physician had ordered the chewable version, not the enteric-coated tablets.
When inspectors interviewed the nurse minutes later, he acknowledged giving only one Fluphenazine tablet instead of two. He also admitted providing enteric-coated aspirin rather than the chewable form ordered by the physician.
The nurse confirmed he had not prepared the Bumex diuretic or any aspirin until the resident pointed out they were missing.
Both the Bumex and aspirin had been ordered since the resident's admission in May. The diuretic helps remove excess fluid from the body, particularly important for patients with heart conditions. The resident had been prescribed daily Bumex and aspirin for nearly five months.
The resident's medical record showed she was cognitively intact and required only supervision with eating, moving in bed, toileting, and transfers. Her quarterly assessment revealed diagnoses including chronic obstructive pulmonary disease, major depressive disorder, and a hormone disorder affecting fluid balance.
Fluphenazine is a powerful antipsychotic medication used to treat schizophrenia and schizoaffective disorder. The difference between one tablet and two represents a 50 percent reduction in the prescribed dose. Underdosing psychiatric medications can lead to symptom relapse and behavioral changes.
The medication administration occurred during the facility's morning medication pass, when nurses distribute drugs to dozens of residents within a compressed timeframe. Federal regulations require nursing homes to ensure medications are given exactly as prescribed by physicians.
The inspection was conducted in response to a complaint filed with state health officials. Inspectors reviewed medication administration practices for four residents during their investigation.
Only one of the four residents experienced medication errors, but the violations affected multiple drugs prescribed for serious medical conditions. The resident's ability to notice and speak up about missing medications prevented her from going an entire day without her prescribed diuretic and aspirin.
The nurse's admission that he failed to prepare two medications until the resident questioned their absence highlighted gaps in the facility's medication verification procedures. Standard nursing practice requires checking physician orders against prepared medications before administration.
Harmony Court Rehab and Nursing must submit a plan of correction to state health officials detailing how it will prevent similar medication errors. The facility has 107 residents who depend on accurate medication administration for conditions ranging from heart disease to psychiatric disorders.
The resident who caught the errors continues to live at the facility, relying on her own vigilance to ensure she receives the psychiatric and cardiac medications prescribed by her physician.
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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