The patient, identified as R2 in inspection records, was admitted to The Terrace with multiple serious conditions including pneumonia, major depressive disorder, severe protein calorie malnutrition, chronic obstructive pulmonary disease, legal blindness, and bipolar disorder. Her hospital discharge instructions from December 18 specifically ordered doxycycline 100 milligrams to be given daily for three days starting December 19.
Instead, staff entered the antibiotic as a "one time only" order rather than a daily medication for the full three-day duration.
R2's electronic medication administration record showed she received doxycycline only once on December 19. The remaining two doses were never administered.
The Director of Nursing acknowledged the error during a December 31 interview with state inspectors. "R2 got her doxycycline on the 19th," she said. "The order was entered for doxycycline 100 mg, 1 capsule by mouth one time only for 3 days."
She explained the fundamental mistake: "The doxycycline should have been scheduled one time a day for the duration of 3 days. R2 received just one dose on the 19th. It looks like the order was entered wrong. It should have been for 3 days."
The medication error occurred despite the facility's policy requiring safe medication administration to prevent such mistakes. The policy, effective since March 2021, establishes guidelines "to ensure that the administration of medications is performed in a safe manner to prevent medication errors."
Doxycycline is a tetracycline antibiotic commonly prescribed for pneumonia and other bacterial infections. The medication requires completion of the full prescribed course to effectively treat infections and prevent antibiotic resistance. Stopping treatment early can allow bacteria to survive and potentially develop resistance to the medication.
For R2, who already faced multiple serious health challenges including severe malnutrition and chronic lung disease, the incomplete antibiotic treatment could have compromised her recovery from pneumonia. Her complex medical conditions, including decreased white blood cell count, made proper infection treatment particularly critical.
The inspection found this was not an isolated system problem but rather a specific data entry error affecting one resident's care. However, the mistake highlights vulnerabilities in the facility's medication management process, particularly in how hospital discharge orders are transcribed into the nursing home's electronic systems.
State inspectors reviewed medication administration for three residents as part of a broader sample of six residents' care. Only R2's medication administration showed deficiencies, suggesting the error was not part of a pattern but represented a breakdown in the facility's medication ordering process.
The facility's electronic medication administration record clearly documented both the incorrect order entry and the missed doses. The system showed the doxycycline order as "give 1 capsule by mouth one time only for 3 days" rather than the correct interpretation of daily administration over three consecutive days.
This type of order entry error demonstrates how miscommunication between hospital discharge planning and nursing home medication management can directly impact patient care. The hospital's discharge instructions were clear about the three-day duration, but the translation into the facility's computer system created a contradiction that staff failed to catch.
The inspection occurred as part of a complaint investigation on December 31, 2025. Inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents.
R2's case illustrates how seemingly minor administrative errors can have significant clinical consequences for vulnerable nursing home residents. With her multiple chronic conditions and recent hospitalization for pneumonia, she needed the full antibiotic course to ensure proper treatment of her infection.
The facility has not indicated whether R2 received alternative treatment for her pneumonia after the medication error was discovered, or whether her condition was affected by the incomplete antibiotic course.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Terrace from 2025-12-31 including all violations, facility responses, and corrective action plans.