Federal inspectors found that Skyview Care and Rehab at Bridgeport discontinued fluoxetine for Resident 3 on October 14 without any documented medical reason. The 10-milligram daily medication treats the resident's diagnosed major depressive disorder.
After realizing the error, staff gave the resident a one-time dose on October 16 at 1:45 PM, then restarted the regular daily schedule the following day. The Regional Nurse Consultant confirmed to inspectors on November 13 that "the order should not have been discontinued on October 14."
Progress notes for October contained no evidence explaining why the psychiatric medication was stopped. The resident's medical records showed fluoxetine was ordered on October 7 and began two days later, only to be inexplicably halted less than a week into treatment.
The medication confusion extended beyond psychiatric drugs. Inspectors discovered similar problems with a completely different resident's ear drops, where staff entered an order incorrectly and had to restart treatment after recognizing their mistake.
Resident 17 was supposed to receive carbamide peroxide otic solution for ear wax buildup starting October 27. The 6.5 percent solution required five drops in the right ear twice daily for eight total administrations. But nursing staff botched the initial order entry on October 21.
The Director of Nursing admitted the error during her November 13 interview with inspectors. She explained that once the facility realized the mistake, "they discussed it with the NP, and they received a new order to start the carbamide peroxide treatment again."
Both cases represent medication administration failures that federal regulators classify as having potential for actual harm to residents. The fluoxetine discontinuation particularly concerned inspectors because antidepressants require consistent dosing to remain effective for patients with major depressive disorder.
Mental health medications like fluoxetine typically take weeks to build therapeutic levels in a patient's system. Interrupting treatment can trigger withdrawal symptoms or mood destabilization, especially dangerous for residents already struggling with severe depression.
The facility's medication tracking systems failed to catch either error before they affected patient care. Monthly medication administration records documented the confusing sequence of orders for both residents but provided no explanation for the treatment interruptions.
For Resident 3, the medication record showed three separate fluoxetine entries within eight days. The original daily order lasted from October 9 to October 14. The single makeup dose appeared on October 16. The corrected daily schedule resumed October 17 and continued through the inspection period.
Staff interviews revealed the facility recognized both mistakes but only after residents had already experienced treatment gaps. The Director of Nursing and Regional Nurse Consultant both acknowledged the errors during separate conversations with federal inspectors.
The carbamide peroxide case demonstrated how medication errors can cascade through a facility's systems. What should have been a straightforward eight-day ear treatment became a multi-week process involving provider consultations and rewritten orders.
Neither resident suffered documented physical harm from the medication interruptions, leading inspectors to classify the violations as "minimal harm or potential for actual harm." However, the finding affects "some" residents, indicating the problems extended beyond these two specific cases.
The inspection occurred November 17 following a complaint about facility operations. Federal regulators found the medication administration deficiencies violated requirements for pharmaceutical services that ensure residents receive appropriate treatment and rehabilitation services.
Skyview Care and Rehab at Bridgeport must submit a plan of correction addressing how they will prevent similar medication errors. The facility operates at 505 O Street in Bridgeport, serving residents who depend on accurate medication management for conditions ranging from depression to basic ear care.
The medication mistakes highlight ongoing challenges nursing homes face maintaining accurate pharmaceutical records. When staff incorrectly enter or discontinue orders, residents can experience treatment gaps that undermine their medical care and recovery progress.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Skyview Care and Rehab At Bridgeport from 2025-11-17 including all violations, facility responses, and corrective action plans.
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