The medication error occurred at Mayfair Village Nursing Care Center during the morning medication round on December 1st. Licensed Practical Nurse #74 crushed Metoprolol Succinate ER, a heart medication, and Potassium CL ER, a supplement for low potassium levels, despite "do not crush" labels on both medication cards.
Both medications are extended-release formulations designed to deliver their active ingredients slowly over time. Crushing them destroys this time-release mechanism, potentially causing dangerous spikes in blood levels or rendering the medications ineffective.
The resident receiving the crushed medications has severe cognitive impairment from dementia and cannot make daily decisions independently. Their medical conditions include chronic kidney disease, heart rhythm problems, high blood pressure, and anemia. They require a pacemaker and take blood thinners long-term.
Federal inspectors observed the medication error during a complaint investigation at the 86-bed facility. At 8:25 a.m., they watched LPN #74 crush three tablets — the two extended-release medications plus Eliquis, a blood thinner — and mix them all in pudding before giving them to Resident #45.
The medication cards for both the heart medication and potassium supplement displayed clear "do not crush" warnings in the left upper corner. The nurse confirmed to inspectors at 9:10 a.m. that she had indeed crushed all three medications.
To verify the severity of the error, another nurse called the facility's pharmacist on speaker phone while inspectors listened. Pharmacist #20 confirmed that both the Metoprolol Succinate ER and Potassium CL ER tablets should never be crushed.
The facility's own medication administration policy requires staff to follow the "10 rights" of medication administration, including verifying the right drug and right dose. The policy instructs nurses to "stop and verify all information before administering" if there are any questions about a medication.
Mayfair Village also has a specific policy for medication errors dating back to 2010. When a medication reaches a resident incorrectly, staff must notify both the pharmacy and the prescribing physician to obtain further instructions. They must also monitor the resident according to the doctor's directions.
The inspection report does not indicate whether facility staff followed these error protocols after the medication mistake was discovered. It also does not specify what monitoring, if any, was conducted for the resident who received the improperly crushed medications.
Extended-release heart medications like Metoprolol Succinate ER are specifically formulated to provide steady blood pressure control throughout the day. Crushing them can cause unpredictable absorption, potentially leading to dangerous drops in blood pressure or inadequate heart rate control.
Similarly, extended-release potassium supplements are designed to prevent stomach irritation and provide gradual absorption. When crushed, they can cause severe gastrointestinal problems and erratic potassium levels that affect heart function.
The medication error affected one of five residents observed during the inspection's medication administration review. Federal inspectors classified the violation as causing "minimal harm or potential for actual harm."
For a resident with multiple heart conditions, kidney disease, and severe dementia, medication errors carry heightened risks. The patient's inability to communicate symptoms or discomfort due to cognitive impairment makes proper medication administration even more critical for their safety and wellbeing.
The inspection was conducted as part of a complaint investigation numbered 2647703, though the report does not detail what prompted the original complaint that led to the federal review.
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.