The medication error occurred at Community Extended Care Hospital of Montclair when Registered Nurse 1 incorrectly entered a Valproic Acid prescription under the wrong resident's chart on December 16, 2025. Resident 1, who needed the anti-seizure medication to manage his medical condition, went without treatment until December 21. Meanwhile, Resident 2 received the medication despite having no clinical need for it.
"I am not sure how the mistake happened; I ended up putting the medication order to the wrong resident," RN 1 told inspectors during a December 30 interview. The nurse acknowledged she should have double-checked the medication order against hospital discharge records and confirmed with the physician before entering the order, but did not.
Valproic Acid is prescribed to prevent seizures and manage certain neurological conditions. Missing doses can lead to breakthrough seizures or other serious complications for patients who depend on the medication for seizure control.
The error persisted for five days despite the facility's stated medication review process. According to the Administrator, the Director of Nursing is supposed to review admission charts the next business day after admission for accuracy and completeness. This review apparently failed to catch the medication mix-up.
RN 1 later admitted the full scope of her error. "It was my mistake that caused Resident [1] did not receive his Valproic Acid to manage his clinical condition that make Resident [2] received Valproic Acid that was unnecessary for her, unfortunately," she told inspectors.
The facility's pharmacist explained that pharmacy staff typically review new admission medication orders within four to eight hours of admission. This review includes checking medication strength, frequency, potential drug interactions, and clinical indication. However, the pharmacist stated that reviewing hospital discharge records "is typically the responsibility of the facility," not the pharmacy.
This division of responsibility may have contributed to the error going undetected. While the pharmacy verified the medication orders as entered, they did not cross-reference them against the original hospital discharge paperwork that would have revealed the mix-up.
The Administrator acknowledged the medication reconciliation practice error during a December 31 interview. She confirmed that Resident 1 missed his prescribed medication needed to manage his medical condition, while Resident 2 received six doses unnecessarily.
Medical records reviewed by inspectors confirmed the timeline of the error. Resident 1's Medication Administration Record showed that Valproic Acid 250 mg, one capsule by mouth three times daily, was not initiated until December 21, 2025. The five-day delay meant the resident missed a total of 12 doses of medication prescribed to manage his clinical condition.
The facility lacked written policies governing the admission process, including medication order procedures. The Administrator acknowledged to inspectors that no written policy existed for medication reconciliation during admissions, despite the critical nature of ensuring patients receive the correct medications upon transfer from hospitals.
Medication errors during care transitions are a recognized patient safety concern. When residents transfer from hospitals to long-term care facilities, accurate medication reconciliation requires careful comparison of hospital discharge orders with facility admission orders to prevent exactly this type of mix-up.
The error only came to light through the inspection process, raising questions about how long it might have continued undetected. Neither the missed doses for Resident 1 nor the unnecessary medication given to Resident 2 were identified through the facility's internal quality assurance processes.
For Resident 1, the five-day gap in anti-seizure medication represented a significant interruption in his prescribed treatment regimen. For Resident 2, receiving unnecessary medication exposed her to potential side effects and drug interactions without any therapeutic benefit.
The inspection found the facility failed to ensure proper medication management during the admission process, a fundamental requirement for safe patient care during care transitions.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Community Extended Care Hospital of Montclair from 2026-01-02 including all violations, facility responses, and corrective action plans.
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