Kittanning Health & Rehab: Medication Error, Unsigned Narcotics - PA
The double dose happened on September 22 at Kittanning Health & Rehab Center, and the resident, identified in inspection records only as Resident R1, had a history of falling and was already being treated for anxiety and depression. The medication at the center of it, lorazepam, is a schedule IV controlled substance. She was prescribed 0.5 milligrams three times a day.
LPN Employee E4 was working the overnight shift. According to her own written statement, she gave the morning dose of Ativan around 6 a.m., signed it out in the narcotic log as administered at 7 a.m., and then, in her words, was "unsure if I gave it or what happened to it." During shift change, she told the oncoming nurse that the residents were good, mentioned it had been a crazy night, and said she was never coming back to the facility. Then she left.
She did not mention the Ativan.
LPN Employee E3 came on for the next shift and gave Resident R1 her morning lorazepam at 10 a.m. She didn't catch the problem right away because, as she later explained in a witness statement, she doesn't sign narcotics out until the end of her shift. It wasn't until the narcotic count at shift's end that LPN Employee E3 realized the number was off. She walked the red narcotic book from Unit 2A to a colleague and reported what had happened.
By that point, the resident had received two doses of a controlled sedative in the span of three hours, with no nurse aware it had happened until after the fact.
The earlier count at 7:15 a.m., the one conducted during the handoff between E4 and E3, had actually flagged the discrepancy and then buried it. LPN Employee E4 said the count showed 23 Ativan tablets. LPN Employee E3 said no, there should be 22. E4 then signed her name in the narcotic book and signed out the medication. E3 assumed the outgoing nurse had simply forgotten to document a dose she'd already given, which would have made the count correct. She noted the assumption in her witness statement: "Nurse assumed she had given the medication and just forgot to sign it out making the count add up."
That assumption was exactly wrong.
A progress note from the same day recorded that a physician was notified and a resident representative was contacted. The note stated the resident did not appear to have any side effects. A second progress note flagged the underlying breakdown: no report from the midnight shift nurse about giving an unscheduled medication, no documentation of a PRN dose in the electronic medical record, nothing passed along at handoff.
The medication error was one piece of a broader documentation failure inspectors found across the facility. Narcotic sign-out logs showed unsigned entries on the 11 p.m. to 7 a.m. shift on November 7, November 10, November 15, and November 17. When inspectors interviewed LPN Employee E2 about the pattern on November 18, the nurse confirmed it and offered a straightforward explanation: "It's mostly night shift that forgets to sign."
The Nursing Home Administrator, interviewed that same afternoon, confirmed that the facility failed to implement procedures for accurate accounting of controlled medications on both of its medication carts, and failed to ensure accurate medication administration, resulting in the error involving Resident R1.
Nobody has said publicly what happened to LPN Employee E4, the nurse who gave the dose, signed it out an hour before she administered it by her own account, then walked out of a shift change without disclosing any of it. Her written statement, completed three days after the incident, described the morning in vague terms. She was unsure if she gave it. She was unsure what happened to it.
Resident R1, who came to the facility managing anxiety, depression, and a history of falls, received a sedating controlled substance twice before 10:30 in the morning. The notes say she showed no adverse effects. The notes also show that no one knew it had happened until hours after the fact, and only then because a nurse doing an end-of-shift count ran the numbers and they didn't add up.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Kittanning Health & Rehab Center from 2025-11-18 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 21, 2026 · Our methodology
KITTANNING HEALTH & REHAB CENTER in KITTANNING, PA was cited for violations during a health inspection on November 18, 2025.
The medication at the center of it, lorazepam, is a schedule IV controlled substance.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.