Federal inspectors found Beaver Dam Health Care Center gave a patient Gabapentin twice daily instead of the prescribed three times daily, effectively reducing his dosage by one-third. The medication treats nerve pain for patients with polyneuropathy, a condition involving damage to peripheral nerves.
The resident, identified as R2 in inspection records, was admitted to the facility in October with a diagnosis of polyneuropathy. His hospital discharge paperwork from October 9 clearly ordered Gabapentin 100 mg capsules "take 1 capsule by mouth every 8 hours."
Every eight hours equals three times per day.
But the facility's active physician orders, printed November 13, showed something different: "Gabapentin 100 mg capsule. Give 1 capsule by mouth two times a day for pain. Scheduled at 8:00 AM and 4:00 PM."
The order was dated October 9, the same day as the hospital discharge.
When inspectors interviewed the facility's nurse practitioner on November 13, she confirmed she had not changed the resident's Gabapentin order. The medication should have been given three times a day, she said.
The unit manager told inspectors that if the hospital discharge paperwork included an order for every eight hours, "the medication should have been put in for 3 times a day."
The Director of Nursing agreed. If the hospital discharge paperwork included an order for every eight hours, the medication should have been scheduled three times daily, she told inspectors.
She called it "a medication error."
The facility's own policy, titled "Preventing and Detecting Adverse Consequences and Medication Errors" and dated October 25, 2014, requires staff to evaluate new medication orders to ensure "the dose, rout of administration, duration, and monitoring are in agreement with the current clinical practice, clinical guidelines, and/or manufacturer's specifications for use."
The inspection found the facility failed to follow this policy.
Gabapentin is commonly prescribed for nerve pain and works by affecting nerve signals in the brain and spinal cord. The medication's effectiveness depends on maintaining consistent levels in the patient's system through regular dosing intervals.
For patients with polyneuropathy, adequate pain control is essential for mobility, sleep, and quality of life. The condition causes burning, tingling, or shooting pain that can be debilitating without proper medication management.
By scheduling the medication twice daily instead of three times, the facility created gaps of 16 hours between the evening dose at 4:00 PM and the morning dose at 8:00 AM. The hospital's original order for every eight hours would have provided more consistent medication levels throughout the day.
The error occurred during the critical transition period when residents move from hospital to nursing home care. Hospital discharge orders must be accurately transcribed into the facility's medication administration system to ensure continuity of care.
Federal regulations require nursing homes to provide pharmaceutical services that meet each resident's needs, including procedures that ensure accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals.
The inspection classified this as a medication error affecting few residents with minimal harm or potential for actual harm. However, for the resident receiving inadequate pain medication, the impact on daily comfort and function could be significant.
The facility's policy acknowledges that medication errors can have adverse consequences and requires evaluation of new orders against clinical practice standards. The transcription error from "every 8 hours" to "two times a day" represents a failure of this basic safety check.
Inspectors conducted the review as part of a complaint investigation on November 13. The facility had been operating under the incorrect medication schedule for over a month, from the resident's admission in early October through the inspection date.
The resident continued to receive the reduced dosage until inspectors identified the discrepancy during their review of medication orders and hospital discharge documentation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Beaver Dam Health Care Center from 2025-11-13 including all violations, facility responses, and corrective action plans.
Additional Resources
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