The October 2 incident at Edenbrook South involved Employee 2, a nurse aide, who gave oral medications, insulin injections, and medications through feeding tubes to residents. Employee 1, a licensed practical nurse, not only knew about the violations but "facilitated" the unlicensed medication administration for two of the three residents.
Pennsylvania law requires specialized training and credentialing for medication administration outside of licensed practical nurse and registered nurse licenses. The nursing assistant had neither.
Employee 2 administered prescribed medications through multiple routes that October evening. She gave oral medications and subcutaneous insulin to Resident 2. She administered medications via PEG tube and gave subcutaneous insulin to Resident 3. She also completed a dressing change on Resident 1's surgical site.
The PEG tube, surgically inserted through the skin of the abdomen directly into the stomach, provides nutrition, fluids, and medications for patients who cannot swallow safely. Subcutaneous injection involves administering medication into the fatty tissue layer between skin and muscle using a short needle.
Employee 1, the LPN who should have been performing these tasks, admitted she "facilitated" the nursing assistant's medication administration for two residents. She also acknowledged knowing that Employee 2 completed the dressing change for Resident 1.
The violations went unreported for nearly a week.
On October 8, someone finally reported to the Director of Nursing that Employee 2 had administered medications. The facility launched an abuse investigation and began interviewing staff to determine if similar events had occurred previously.
Resident 1 recalled the incident during a December 23 interview with state inspectors. He remembered "a night when an NA had completed a treatment for him on his leg." Residents 2 and 3 were not available for interview during the inspection.
The facility assessed all three residents on October 8 for negative outcomes related to the unlicensed medication administration. None were observed, according to facility documentation.
Both employees were terminated.
The facility initiated education on scope of practice and job duties for all nursing staff on October 8, completing the training by October 14. Management also began routine auditing of medication administrations following the incident.
Federal inspectors classified the violation as causing "minimal harm or potential for actual harm" to residents. The deficiency affected "few" residents at the
The inspection, conducted December 23 in response to a complaint, found the facility failed to ensure care and services were provided in accordance with professional standards of quality. The violation represents past non-compliance, meaning the facility had already taken corrective action before inspectors arrived.
State regulations require nursing facilities to maintain management oversight of clinical services and ensure nursing services meet professional standards. The unlicensed medication administration violated both requirements.
Employee 2's statement to investigators detailed the extent of her unauthorized activities that October night. She administered medications through three different routes - oral, PEG tube, and subcutaneous injection - representing a significant scope of practice violation for an unlicensed aide.
The licensed practical nurse's role in facilitating the violations compounded the regulatory breach. LPNs are responsible for medication administration and cannot delegate these duties to unlicensed personnel under Pennsylvania regulations.
Medication administration requires specific training in drug interactions, dosing calculations, administration techniques, and monitoring for adverse reactions. Nursing assistants receive training in basic care activities like bathing, feeding, and positioning, but not in clinical nursing functions like medication administration or wound care.
The dressing change on Resident 1's surgical site represented another scope of practice violation. Wound care requires assessment skills to identify signs of infection, improper healing, or complications that nursing assistants are not trained to recognize.
Insulin administration carries particular risks when performed by unlicensed personnel. The hormone requires precise dosing based on blood sugar levels, meal timing, and individual patient factors. Incorrect administration can cause dangerous blood sugar fluctuations leading to confusion, loss of consciousness, or medical emergencies.
PEG tube medication administration involves additional complexities, including proper tube placement verification, medication compatibility with tube feeding formulas, and recognition of complications like tube blockages or displacement.
The six-day delay between the incident and reporting to the Director of Nursing suggests potential gaps in the facility's internal monitoring systems. Professional standards require immediate reporting of scope of practice violations and potential patient safety incidents.
The facility's post-incident response included comprehensive staff interviews to identify similar violations, suggesting management recognized the potential for widespread practice issues. The implementation of routine medication administration audits indicates the facility identified systemic oversight deficiencies.
Employee terminations for both the nursing assistant and licensed practical nurse reflected the seriousness of the violations. The LPN's facilitation of unlicensed practice represents a significant breach of professional responsibility and regulatory requirements.
The education initiative covering all nursing staff suggests the facility identified knowledge gaps regarding scope of practice limitations across multiple employees, not just the two individuals directly involved in the October 2 incident.
State inspectors reviewed the facility's corrective actions and compliance audits during their December visit, finding evidence of ongoing monitoring and education efforts to prevent recurrence of unlicensed medication administration.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Edenbrook South from 2025-12-23 including all violations, facility responses, and corrective action plans.