RN 3 gave Resident 1 regular amphotericin B instead of the prescribed amphotericin B liposomal (AmBisome) for treatment of mucormycosis, a serious fungal infection. The resident weighed 69.5 kilograms, and the packaging clearly warned in red font that "Amphotericin B should not be given at dosages greater than 1.5mg/kg."
The medication mix-up occurred at Pacific Haven Subacute and Healthcare Center on the night shift. At 8:52 p.m., Pharmacy 1 delivered seven vials of amphotericin B 50 mg along with dextrose solution to RN 3. Six hours later, at 12:38 a.m., the nurse administered the wrong medication to the resident.
RN 3 told inspectors he had never given amphotericin B before and "did not realize there was a difference between the two medications." When shown the physician's order during an interview, he verified that the packaging from Pharmacy 1 "did not match the verbiage on the resident's physician's order written on the IV MAR."
Despite the dosage warning printed in red on the packaging, RN 3 admitted he "did not double check and compare the dosage warnings on the amphotericin B packaging against the resident's physician's order." He also said he "did not research the medication prior to administering it" but acknowledged "he should have double checked."
The nurse revealed he had "never been trained on how to administer amphotericin B products, or how to reconstitute and prepare IV medications."
This admission exposed a broader training gap at the facility. When inspectors interviewed the Director of Nursing, she said she "expected the licensed nurses to look up a medication they have not administered before." But the expectation wasn't backed by formal training or competency verification.
RN 2 told inspectors that while a pharmacy consultant had observed her during her first medication administration, "the facility had not observed her or signed her off when she had to reconstitute the IV medications."
The Administrator and Clinical Consultant confirmed the training deficiency when questioned by inspectors. The Clinical Consultant "verified the RN staff should have been trained and signed off for competency prior to reconstituting IV medications."
Amphotericin B and amphotericin B liposomal are both antifungal medications, but they have different formulations and dosing requirements. The liposomal version is designed to reduce toxicity while maintaining effectiveness against serious fungal infections like mucormycosis.
The facility's pharmacy delivery log confirmed that both the wrong medication and the dextrose solution arrived together at 8:52 p.m. on the day of the incident. The delivery was signed for by RN 3, who six hours later mixed and administered the medication without recognizing the discrepancy.
Federal inspectors found the incident represented actual harm to the resident and violated medication administration standards. The facility's failure to train nurses on IV medication preparation and reconstitution created conditions where dangerous medication errors could occur.
The Clinical Consultant told inspectors the facility would conduct training on IV medication reconstitution for the nursing staff. But for Resident 1, the training came too late.
The wrong medication had already been administered, exceeding the dosage limits that the manufacturer had printed in red as a warning on every package.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pacific Haven Subacute and Healthcare Center from 2025-11-04 including all violations, facility responses, and corrective action plans.
Additional Resources
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