Resident #39 received the wrong form of his 81-milligram aspirin dose on November 20 when RN #361 dispensed the medication from a bottle labeled as chewable tablets, according to the inspection report. The nurse placed the chewable aspirin in the same cup as the resident's other morning medications in tablet and capsule forms.
Inspectors observed the resident pour the entire cupful of pills into his mouth and swallow them together with water, including the chewable aspirin that was designed to be chewed rather than swallowed whole.
The resident's medical order specifically called for an 81-milligram oral capsule, not a chewable tablet. During an interview at 8:45 a.m. on November 20, RN #361 confirmed to inspectors that the aspirin came from a bottle indicating it was a chewable tablet and that the resident swallowed the medication instead of chewing it.
The nurse acknowledged the discrepancy between the prescribed capsule form and what was actually given. RN #361 told inspectors the facility did not stock low-dose aspirin in capsule form, carrying only enteric coated aspirin and chewable tablets.
This medication error violated the facility's own policies for safe drug administration. The facility's Medication Administration General Guidelines, last revised in August 2014, required medications to be given exactly as prescribed. The policy mandated that nurses verify medication orders against medication labels and ensure the right medication was given to the right resident using the correct dose, route, and timing.
The inspection found the nurse failed to follow these basic safety protocols. By dispensing chewable tablets when capsules were ordered, and allowing the resident to swallow rather than chew the medication, staff violated multiple aspects of the "five rights" of medication administration.
Federal inspectors classified the violation as having minimal harm or potential for actual harm, affecting few residents. The deficiency was investigated as part of complaint #1401318 filed against the facility.
The medication mix-up raises questions about the facility's inventory management and staff training on proper drug administration. While low-dose aspirin is commonly prescribed for cardiovascular protection in elderly patients, the specific formulation matters for proper absorption and effectiveness.
Chewable aspirin tablets are formulated differently than capsules and are designed to be broken down by chewing before swallowing. When swallowed whole, they may not dissolve or absorb properly in the digestive system, potentially affecting the medication's therapeutic benefit.
The error also highlights gaps in the facility's medication verification process. Standard nursing practice requires checking that the form of medication matches the written order before administration, particularly when substitutions might affect how the drug works in the patient's system.
RN #361's admission that the facility routinely lacked the prescribed capsule form suggests this may not have been an isolated incident. The nurse's matter-of-fact acknowledgment that they didn't stock the ordered medication indicates potential systemic issues with pharmacy inventory or prescribing practices.
The facility's medication policy emphasized the critical importance of adhering to prescribed routes of administration. Oral capsules and chewable tablets represent different routes that can affect drug absorption, onset, and effectiveness, making the distinction medically significant rather than merely administrative.
Avenue at Broadview Heights, located at 1201 Akins Road, underwent the inspection on November 25 following the complaint. The Centers for Medicare and Medicaid Services documented the violation under federal tag F0759, which covers medication administration requirements.
The inspection report noted that this represented non-compliance with federal nursing home regulations requiring proper medication management. Facilities must ensure residents receive medications exactly as prescribed by their physicians, without unauthorized substitutions or changes to administration methods.
For Resident #39, the consequence was receiving his prescribed aspirin in a form that may not have provided the intended therapeutic effect. The resident trusted that the pills in his medication cup were prepared correctly and swallowed them as he had been taught, unaware that one required different handling.
The violation underscores the complex medication management challenges facing nursing homes, where residents often take multiple daily medications that require precise administration. When staff shortcuts or inventory limitations compromise these protocols, residents bear the medical risks of receiving treatments that may not work as their doctors intended.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avenue At Broadview Heights from 2025-11-25 including all violations, facility responses, and corrective action plans.