The nurse administered regular amphotericin B instead of the ordered amphotericin B liposomal medication to a 69.5-kilogram resident at Pacific Haven Subacute and Healthcare Center. The packaging clearly displayed a red warning: "Amphotericin B should not be given at dosages greater than 1.5mg/kg."
For this resident's weight, the maximum safe dose was 104.25 mg. But the nurse mixed the medication incorrectly, creating a solution with a final concentration of 1.4 mg/ml — far exceeding the manufacturer's recommended concentration of 0.1 mg/ml.
RN 3 told investigators he "did not double check and compare the dosage warnings on the amphotericin B packaging against the resident's physician's order." He admitted he "did not research the medication prior to administering it" and acknowledged he "should have double checked."
The pharmacy's Chief Compliance Officer explained the severity of the error. The amphotericin B should have been mixed in 3,500 ml of fluid and infused over four to six hours. Instead, the nurse mixed it in just 250 ml and administered it over two hours.
"Any side effects from the amphotericin B medication would have been exacerbated at higher dosages," the pharmacy official stated.
Both amphotericin B and amphotericin B liposomal are classified as high alert medications because of their "risk of causing serious harm." Pharmacies are required to place high alert labels on these medications to warn caregivers about drugs with similar-sounding names.
The pharmacy failed to place the required high alert label on the amphotericin B bag delivered to Pacific Haven.
The Director of Nursing confirmed that licensed nurses were expected to verify medication name, concentration, and formula against physician orders and prescription labels. Nurses must follow the six rights of medication administration: right patient, right medication, right dose, right time, right route, and right to refuse.
"The right medication, and the right dose were not followed when RN 3 administered the amphotericin B to Resident 1, instead of the amphotericin B liposomal (AmBisome) as ordered," the Director of Nursing acknowledged.
The inspection classified this as causing "actual harm" to the resident.
Amphotericin B is a powerful antifungal medication used to treat serious fungal infections. The liposomal formulation, AmBisome, is designed to reduce the drug's toxicity while maintaining effectiveness. Regular amphotericin B can cause severe side effects including kidney damage, heart problems, and dangerous drops in blood pressure.
The concentration error meant the resident received a solution that was 1,400 percent stronger than recommended. The shortened infusion time further increased the risk of serious complications.
High alert medications require special handling precisely because mix-ups can be fatal. The Institute for Safe Medication Practices maintains a list of drugs that have "a heightened risk of causing significant patient harm when they are used in error."
The pharmacy's failure to properly label the high-risk medication removed a critical safety barrier. The red warning text on the packaging represented the last line of defense against a potentially lethal dosing error.
RN 3's admission that he failed to research the medication or verify dosage warnings suggests a breakdown in basic nursing protocols. Standard practice requires nurses to cross-reference unfamiliar medications and verify all dosing parameters before administration.
The resident's weight of 69.5 kg made the calculation straightforward. At the maximum safe dose of 1.5 mg/kg, this patient should have received no more than 104.25 mg total. The concentrated solution the nurse prepared could have delivered far more.
Federal inspectors found that Pacific Haven failed to ensure medications were administered according to physician orders and accepted standards of practice. The violation affected few residents but caused actual harm.
The case illustrates how multiple safety failures can compound. The pharmacy omitted required warning labels. The nurse skipped verification steps. The facility's systems failed to catch the error before it reached the patient.
For the resident who received the wrong medication at a dangerous concentration, these systemic failures had immediate consequences. The inspection report documents actual harm occurred, though the specific medical effects on this patient remain between the lines of regulatory language.
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
- View all inspection reports for Pacific Haven Subacute and Healthcare Center
- Browse all CA nursing home inspections