Federal inspectors found the documentation gaps at Northern Dauphin Nursing and Rehabilitation Center during a December 23 complaint investigation. The violations involved Employee 1, whose name was redacted from the inspection report, and her handling of oxycodone prescribed for two residents.
The most glaring discrepancy occurred on December 6. Employee 1 signed the drug record showing she dispensed oxycodone to Resident 6 at 2:30 PM. But she didn't clock in for work until 2:42 PM that day, twelve minutes after the documented medication time.
When she did give Resident 6 the oxycodone at 2:30 PM, Employee 1 didn't sign off on the medication administration record until 3:35 PM, more than an hour later.
The pattern continued throughout her shift. At 6:30 PM, she dispensed oxycodone to the same resident but waited until 7:26 PM to document it on the medication administration record. Later that evening at 10:30 PM, she managed to sign off immediately after giving the dose.
Resident 6 had been prescribed oxycodone 5 mg, with instructions to give 10 mg every four hours as needed for severe pain. The resident's medical record showed diagnoses including high blood pressure and Type 2 diabetes. Resident 6 was discharged from the facility on December 18 and could not be interviewed by inspectors.
Employee 1's documentation problems extended to other residents as well. On December 2, she dispensed oxycodone to Resident 5 at 9:00 PM but didn't sign the medication administration record until 9:09 PM. Resident 5 was unable to be interviewed during the inspection.
The oxycodone given to Resident 5 on December 2 appeared to be the only dose documented for that resident during the entire month of December, according to the medication administration record reviewed by inspectors as of December 22.
Inspectors also discovered that Employee 1 had not worked at all on December 1, despite some documentation suggesting otherwise.
During the investigation, Employee 1 provided an undated written statement about her December 7 shift, which ran from 3:00 PM to 7:00 AM. In the statement, she claimed that "all medications given during the shift were documented and signed off in both the electronic medication administration record and the paper medication book immediately after administration."
The inspection findings contradicted her written assertion about immediate documentation.
When inspectors interviewed facility leadership on December 22, the Director of Nursing and Assistant Director of Nursing acknowledged the problems. Both officials stated that nurses should document controlled substances "within a couple minutes of dispensing the medication, not an hour or more later."
They emphasized that medications should be documented every time they are administered to residents.
The violations fell under Pennsylvania nursing home regulations governing the responsibility of licensees and nursing services requirements. Federal inspectors classified the harm level as minimal, with few residents affected.
The timing discrepancies raise questions about medication security and resident safety at the 120-bed facility. Controlled substances like oxycodone require strict documentation to prevent diversion and ensure residents receive prescribed doses when needed.
Employee 1's practice of signing medication records long after dispensing doses, or in one case before even arriving at work, undermines the tracking systems designed to protect both residents and the facility from regulatory violations.
The inspection report did not indicate whether Employee 1 faced disciplinary action or whether the facility implemented new procedures to prevent similar documentation gaps. Resident 6's discharge before the investigation prevented inspectors from determining whether the delayed documentation affected the resident's pain management or overall care.
Northern Dauphin Nursing and Rehabilitation Center operates as a for-profit facility in this small Pennsylvania town about 30 miles north of Harrisburg. The December complaint investigation focused specifically on medication administration practices, though the report did not detail what prompted the initial complaint.
The facility's leadership acknowledged the documentation requirements during interviews but provided no explanation for why Employee 1's violations had gone undetected before the federal inspection.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Northern Dauphin Nursing and Rehabilitation Center from 2025-12-23 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Northern Dauphin Nursing and Rehabilitation Center
- Browse all PA nursing home inspections