Resident 45 at Harrison Pavilion Care Center was supposed to receive Meropenem, a powerful antibiotic, every eight hours through an IV to treat an infected sacral wound. Instead, the resident missed seven consecutive doses between November 14 and November 17, according to federal inspection records.
The resident had been admitted to the 78-bed facility in March 2024 with multiple health problems including a pressure ulcer on the sacral region and moderate cognitive impairment. A physician ordered the antibiotic treatment on November 11 for a 14-day course to fight the infected wound.
The pharmacy delivered 24 bags of the medication on November 11, enough for eight days of treatment. But starting on November 14 at 9 p.m., doses began getting skipped.
Pharmacy progress notes from November 15 through November 17 repeatedly documented the same reason for missed doses: "medication was on order." The notes appeared at 4:55 a.m., 11:09 p.m., 5:11 a.m., 4:15 p.m., 8:41 p.m., and 4:52 a.m. as dose after dose went unadministered.
The facility's Director of Nursing confirmed during a November 26 interview that Resident 45 had indeed missed the Meropenem doses on all four days. When pressed for an explanation, the nursing director revealed the underlying cause: an agency nurse was working those shifts and "didn't ask where the IV medications were stored."
The pharmacy had to send a second shipment of 21 bags on November 18, seven days after the original delivery, to continue treatment that should have been uninterrupted.
Harrison Pavilion's own medication policy, revised in April 2019, requires medications to be "administered in a safe and timely manner, and as prescribed." The policy specifically states that medications must be given within one hour of their prescribed time unless otherwise specified.
For antibiotics like Meropenem, timing matters critically. The medication works by maintaining consistent levels in the bloodstream to fight bacterial infections. Missing multiple doses can reduce effectiveness and potentially contribute to antibiotic resistance.
The resident's medical complexity made the medication errors particularly concerning. Beyond the infected wound requiring antibiotic treatment, Resident 45 had been diagnosed with hyperosmolality and hypernatremia, conditions involving dangerous imbalances of water and sodium in the body, as well as major depressive disorder.
The cognitive impairment documented in the resident's quarterly assessment meant they likely couldn't advocate for themselves or alert staff when scheduled medications didn't arrive. The resident scored 10 on the Brief Interview for Mental Status, indicating moderate cognitive decline.
Federal inspectors found the violation during a complaint investigation in November 2025. The inspection focused on medication administration practices after receiving complaint number 2639823, though the specific nature of the original complaint wasn't detailed in the report.
The pharmacy representative interviewed during the inspection confirmed the timeline of deliveries but offered no explanation for why the facility's nursing staff couldn't locate medications that had been properly delivered and should have been readily available.
Agency nurses, temporary staff brought in to cover shifts when regular employees aren't available, often work at multiple facilities and may be unfamiliar with specific locations and procedures at each site. However, ensuring they can access and administer prescribed medications falls to the facility's management.
The missed doses represented a clear breakdown in the facility's medication management system. While the pharmacy delivered the correct medication on time, the nursing home failed to ensure its temporary staff could locate and administer treatments that residents needed around the clock.
Harrison Pavilion Care Center, located on Harrison Avenue in Cincinnati, has operated as a skilled nursing facility serving elderly and disabled residents requiring long-term care and rehabilitation services. The facility was cited for minimal harm or potential for actual harm related to the medication errors.
The inspection found that one resident out of three reviewed for medication administration experienced significant medication errors. For Resident 45, those errors meant four days without the antibiotic treatment prescribed to fight an infection that had already compromised their health.
The case illustrates how staffing challenges in nursing homes can directly impact patient care, even when medications are properly ordered and delivered. When temporary staff lack basic orientation about medication storage locations, residents pay the price through missed treatments and prolonged infections.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Harrison Pavilion Care Center from 2025-11-26 including all violations, facility responses, and corrective action plans.
Additional Resources
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