Video footage captured the October 17 incident at 7:30 p.m., about 20 minutes after the aide had already given the resident their prescribed medications. The facility's investigative report documented the timeline through security cameras.
Staff B, the certified medication aide, had been in the middle of her medication pass when she answered a telephone call among other interruptions. A resident's pressure alarm then went off. The aide rushed to help the resident back into her recliner after she had scooted to the edge and tried to stand up.
During the commotion, the aide had another resident's medications already crushed in a cup with a spoon. She erroneously gave Resident #3 those medications instead.
The wrong medications included Melatonin 3 milligrams, Mirtazapine 15 mg, Alprazolam 0.75 mg, and Apixaban 2.5 mg. Apixaban is an anti-coagulant blood thinner. Mirtazapine is an anti-depressant. The Alprazolam dose was three times stronger than what the resident normally received.
Twenty minutes earlier, at 7:10 p.m., the same aide had correctly administered Resident #3's prescribed evening medications. Those included Buspirone Hydrochloride 5 mg for anxiety, Acetaminophen 325 mg for pain, Alprazolam 0.25 mg for anxiety, Melatonin 5 mg, and Pepcid 20 mg to reduce stomach acid.
A licensed practical nurse documented the medication error on a form dated the same day. The Director of Nursing confirmed in a written statement that Resident #3 received medications prescribed for Resident #6 at approximately 6:36 p.m.
Federal inspectors found a second medication error involving a different resident. Staff discovered during rounds that Resident #5 had been receiving duplicate doses of the antipsychotic medication Seroquel.
The resident continued getting both Seroquel 12.5 mg and Seroquel 25 mg in the morning even after the physician changed the order on August 28. The new prescription called for Seroquel 25 mg in the morning and 12.5 mg at noon and supper.
Staff documented this error on September 10, more than two weeks after the physician changed the prescription. An incident report noted the discovery at 4:28 p.m. during medication rounds.
The facility failed to ensure two of three residents remained free from significant medication errors during the federal inspection. Inspectors reviewed video footage, clinical records, and interviewed staff to document the violations.
Both incidents involved fundamental medication safety failures. In the first case, interruptions during the medication pass led to a resident receiving the wrong medications entirely. The blood thinner posed particular risks given that the resident wasn't prescribed anticoagulation therapy.
The second error involved staff failing to update medication administration after a physician changed prescriptions. The resident received nearly double their intended morning Seroquel dose for over two weeks.
Federal regulations require nursing homes to ensure residents remain free from significant medication errors. The violations at Northgate Care Center resulted in a finding of minimal harm or potential for actual harm.
The facility's own investigative processes documented both errors through video review and incident reports. Security footage provided a detailed timeline of the evening medication pass that led to the wrong medications being administered.
Staff interviews and clinical record reviews supported the findings. The licensed practical nurse who documented the first error provided details about the interruptions that contributed to the mistake.
Medication errors in nursing homes can have serious consequences, particularly when they involve blood thinners or psychiatric medications. Wrong doses of antipsychotic drugs like Seroquel can cause sedation, falls, or other adverse effects in elderly residents.
The October incident highlighted how interruptions during medication passes can compromise patient safety. Phone calls and resident emergencies created the conditions that led to one resident receiving another's crushed medications.
Both residents affected by the medication errors were among the facility's most vulnerable patients, requiring multiple daily medications for complex medical conditions. The errors occurred despite established protocols designed to prevent such mistakes.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Northgate Care Center from 2025-11-14 including all violations, facility responses, and corrective action plans.