The medication error involved a resident with severe cognitive impairment who has lived at the facility since April 2019. The patient suffers from dementia, psychotic and mood disturbances, chronic kidney disease, atrial fibrillation, hypertension, and uses anticoagulants long-term.
On December 1, inspectors watched Licensed Practical Nurse #74 administer morning medications to the resident at 8:25 a.m. The nurse crushed three tablets — Metoprolol Succinate ER 100mg for hypertension, Potassium CL ER 20 mEq for low potassium, and Eliquis 2.5 mg — then mixed all three into pudding.
Both the heart medication and potassium supplement were labeled "do not crush" in the upper left corner of their medication cards.
The resident's cognitive assessment could not be completed because staff noted the patient is "rarely/never understood." Decision-making skills were documented as severely impaired.
When questioned 45 minutes later, the nurse confirmed crushing and administering the three medications. The facility's own pharmacist, contacted by speaker phone during the inspection, confirmed that both the extended-release Metoprolol and potassium tablets should never be crushed.
Extended-release medications are designed to dissolve slowly over time. Crushing them can release the full dose immediately, potentially causing dangerous blood pressure drops or heart rhythm problems.
The Metoprolol prescription specifically instructs staff to hold the medication if the patient's systolic blood pressure falls below 110. The order has been in place since December 23, 2024. The potassium supplement has been prescribed since December 22, 2019.
Mayfair Village's own medication policy requires staff to follow the "10 rights" of drug administration, including verifying the right drug by comparing orders with medication records three times and checking labels against electronic records. Staff must verify the correct dose, and if any doubt exists, they must stop and verify all information before giving medications.
The facility's error policy states that when medications reach residents incorrectly, staff should notify the pharmacy and physician immediately for further instructions. Staff must monitor the resident according to physician orders.
The 86-bed facility failed to follow these protocols.
This represents the kind of basic medication safety failure that can have serious consequences for vulnerable residents. The patient involved has multiple heart conditions, kidney disease, and takes blood thinners — all conditions that make medication timing and dosing critical.
The resident's complex medical history includes a cardiac pacemaker, swallowing difficulties, muscle weakness, and anemia. Managing medications for someone with this many conditions requires precise adherence to prescribing instructions.
Federal inspectors classified this as minimal harm with potential for actual harm. But crushing extended-release heart medications for a patient with atrial fibrillation and hypertension creates risks for blood pressure emergencies or heart rhythm disturbances.
The inspection was conducted in response to a complaint filed as case number 2647703. The facility has not yet submitted its plan of correction to state regulators.
Mayfair Village operates at 3000 Bethel Road in Columbus. The medication error affected one of five residents observed during the inspection's medication administration review.
The violation demonstrates how basic safety protocols can break down even when clear warning labels are present and facility policies explicitly require verification steps. For a resident who cannot communicate effectively about symptoms or side effects, such errors carry heightened risks.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mayfair Village Nursing Care C from 2025-12-01 including all violations, facility responses, and corrective action plans.