The medication error at Continuing Care at Lantern Hill involved residents receiving each other's IV antibiotic treatments. One resident was prescribed piperacillin-tazobactam for osteomyelitis of the first distal phalanx, a bone infection requiring a 32-day course of the powerful antibiotic every eight hours.
Federal inspectors found the nurse had passed medication administration competencies with both the assistant director of nursing and the facility's pharmacist consultant. She had attended required education sessions and worked at the facility for approximately four months before the December incident.
The resident who received the wrong medication experienced immediate adverse reactions. At lunchtime on December 3rd, the patient vomited once, developed facial flushing and felt cold with chills. A physician came to bedside and the resident was transferred to the emergency room.
The second resident who received incorrect antibiotics showed no adverse reactions to the medication error.
The facility's Director of Nursing told federal inspectors that LPN #1 failed to follow medication administration procedures despite the education and training she had received. The Licensed Nursing Home Administrator confirmed the nurse was suspended pending investigation on December 3rd and terminated on December 9th.
Both residents required close monitoring after receiving the wrong medications. Physicians were notified immediately when staff discovered the error.
Federal inspectors classified the violation as immediate jeopardy to resident health or safety, the most serious category of nursing home deficiency. The finding indicates conditions that caused or were likely to cause serious injury, harm, impairment or death.
The facility's medication administration records showed the discontinued antibiotic order for piperacillin-tazobactam, with the nurse's initials indicating she had administered the medication on the morning of December 3rd. The antibiotic was prescribed specifically for treating bone infection in the resident's finger.
Following the medication error, Continuing Care at Lantern Hill implemented immediate corrective measures. The assistant director of nursing conducted a complete audit of all residents with physician orders for IV antibiotics to verify correct medications were available and properly stored in the medication room.
The facility began mandatory medication administration education on December 3rd, requiring all nursing staff to complete training and IV competencies before their next scheduled shift. All newly hired nurses must now receive education on proper medication administration with return demonstrations during orientation.
Starting December 4th, the facility created a new verification process requiring two nurses to confirm the correct IV medication before administration to any resident. Random audits began monitoring nurses administering intravenous medications.
The nurse who made the error demonstrated competency on a medication administration observation checklist immediately after the mistake was discovered, according to facility records. However, this demonstration came after she had already administered incorrect medications to two residents.
One resident's care plan specifically included goals for nurses and caregivers to "administer my medications as prescribed and monitor for side effects daily." The resident required assistance from staff for activities of daily living and was taking antibiotics as part of their treatment plan.
The facility submitted a removal plan on December 19th detailing actions to prevent similar incidents. Federal inspectors verified implementation of corrective measures during their return visit on December 23rd.
The December 3rd medication error occurred despite the facility's existing protocols and the nurse's documented competency assessments. The incident highlighted gaps between training completion and actual medication administration practices at the 315-bed facility.
The resident who went to the emergency room had been receiving the prescribed antibiotic since November 13th as part of treatment for the bone infection. The medication was scheduled every eight hours, requiring precise timing and dosing for effective treatment of osteomyelitis.
Federal regulations require nursing homes to ensure residents receive medications as prescribed and monitor for adverse effects. The wrong antibiotic administration violated these fundamental patient safety requirements and put both residents at risk for serious complications.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Continuing Care At Lantern Hill from 2025-12-23 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Continuing Care At Lantern Hill
- Browse all NJ nursing home inspections