The medication error occurred on November 20 at Alexandria Care Center, where Licensed Vocational Nurse 1 administered guaifenesin at 4:56 a.m. and dextromethorphan-guaifenesin at 8 a.m. to the same resident. During interviews with federal inspectors on December 24, the nurse acknowledged both medications were identical and should have been spaced six hours apart.
"LVN 1 stated Resident 1 could experience overdose of the cough medicine," inspectors wrote.
The Director of Student Development confirmed nurses failed to follow physician orders. "The DSD stated the nurses did not clarify and did not follow the order," according to the inspection report. The administrator said the resident "could have upset stomach" from the double dosing.
A registered nurse warned of more severe consequences. RN 1 told inspectors the resident "could experience nausea, vomiting and other negative side effects" and noted the resident "could also experience increase heart rate and can get drowsy from cough medicine when given too close from the last dose."
The facility's Director of Nursing described additional risks during her December 24 interview. She said the resident "could possibly get drowsy and can have low blood pressure from taking the cough medication less than six hours" apart.
Inspectors also discovered confusion over stomach medication dosing for the same resident. The Director of Nursing told investigators that "nurses should have clarified the famotidine order on which one to follow, the daily or the before breakfast." She warned that "Resident 1 could overdose with the famotidine."
The registered nurse explained potential consequences of double famotidine doses, stating the resident "could experience nausea, vomiting and other negative side effects from receiving two doses."
Federal inspectors found the medication errors violated the facility's own policies. Alexandria Care Center's medication administration procedures, last reviewed in January 2025, require that "medications are administered in a safe and timely manner, and as prescribed" and "in accordance with prescriber orders, including any required time frame."
The policy specifically instructs staff to contact prescribing physicians "if a dosage is believed to be inappropriate or excessive for a resident" or if medication "has been identified as having potential adverse consequences for the resident."
The facility's medication safety protocols also mandate that nurses "check the label three times to verify the right resident, right medication, right dosage, right time and right method of administration before giving the medication."
Despite these written safeguards, the Director of Nursing acknowledged to inspectors that "nurses did not follow the physician order for the cough medicine."
The violations occurred during a complaint investigation at the 1515 N Alexandria Avenue facility. Inspectors classified the deficiency as causing "minimal harm or potential for actual harm" affecting "some" residents.
The medication errors highlight systemic problems with nurse training and oversight at Alexandria Care Center. Multiple staff members interviewed by inspectors demonstrated confusion about basic medication protocols, with the original nurse stating that identical medications with the same active ingredient were somehow different drugs.
The timing of the cough medicine doses created particular concern among facility leadership. Administering the medications just three hours apart meant the resident received nearly double the intended dosage in a compressed timeframe, significantly increasing risks of adverse reactions.
The stomach medication confusion revealed additional gaps in nursing protocols. The existence of conflicting physician orders for famotidine dosing should have triggered immediate clarification with the prescribing doctor, according to the facility's own policies.
Instead, nurses apparently made independent decisions about which order to follow, creating potential for dangerous drug interactions and overdosing.
The December inspection occurred more than a month after the November medication errors, suggesting the problems may have persisted undetected for weeks. The facility's internal monitoring systems failed to identify the dangerous dosing patterns until federal investigators arrived.
Alexandria Care Center's medication administration failures put vulnerable residents at risk of serious harm from preventable nursing errors and inadequate supervision of drug protocols.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Alexandria Care Center from 2025-12-30 including all violations, facility responses, and corrective action plans.