Susquehanna Health and Wellness: Wrong Meds Sent Resident to ER - PA

The incident happened on March 21, 2026, at Susquehanna Health and Wellness Center, according to a federal inspection report. The nurse, identified in the report as Licensed Practical Nurse Employee E3, entered the room intending to give medication to the resident in the B bed. She called out that resident's name. The resident in the A bed answered yes and asked to be turned toward the door. The nurse gave that resident the medication.

What followed was a medical emergency. Hospital records obtained by inspectors show the resident, identified as Resident R1, was admitted the same day. Under the section labeled Impression/Plan, the hospital documented: "Accidental drug ingestion: pt residents at Susquehanna N&R and was accidentally given his/her roommates medications including Ativan (lorazepam), Keppra (levetiracetam), Gabapentin, Morphine, and Xcorpi with resultant lethargy and hypotension."

The hospital treated the resident with Narcan, intravenous fluids, and telemetry monitoring. Doctors noted the patient may need additional fluids and reversal agents.

The medications the resident received were not minor. The roommate's drug regimen included lorazepam, a sedative used for anxiety and insomnia; morphine sulfate, used for moderate to severe pain; acetaminophen; Carbidopa-Levodopa, prescribed for Parkinson's disease; and Gabapentin, used to control seizures and reduce pain. None of those medications had been prescribed for Resident R1.

The nurse had completed medication administration education two days earlier, on March 19, 2026.

The facility caught its own mistake. Administrators launched a quality assurance review the same day, checked all other residents on the unit who had received medication from the nurse that day, and monitored them for adverse effects, including obtaining vital signs. The nursing home administrator confirmed the findings to inspectors on March 31, 2026.

LPN Employee E3 was suspended and told she could return to work after additional mentoring and a medication administration competency review were completed.

The facility's corrective response moved quickly. By March 23, the Director of Nursing had completed education for all nursing staff on proper resident identification before giving medications. That same day, the Director of Nursing sat down with RN supervisor Employee E4 specifically to go over when the DON must be notified of a significant medication error and when an RN has the authority to transfer a resident to the hospital without waiting.

That second piece of education raises a question the inspection report does not fully answer: how long did it take to get Resident R1 to the hospital after the wrong medications were administered, and who made that call.

By March 28, medication pass audits had been completed for all licensed nurses currently on staff. Three nurses interviewed by inspectors on March 31 — LPN Employee E5, RN Employee E6, and LPN Employee E7 — each confirmed they had received the training and could explain what it required. Employee E7 added that all residents now have updated photographs in their charts, and that if a nurse cannot identify a resident, they are to ask another staff member for help.

The inspection was triggered by a complaint. The violation was cited at the level of actual harm.

Resident R1 was hospitalized on March 21, 2026, after receiving drugs that were not prescribed to them, became lethargic and hypotensive, and required a medication specifically designed to reverse opioid overdose. The inspection report does not say when the resident was discharged, or what condition they were in when they left the hospital.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Susquehanna Health and Wellness Center from 2026-03-31 including all violations, facility responses, and corrective action plans.

Additional Resources

• View all inspection reports for Susquehanna Health and Wellness Center
• Browse all PA nursing home inspections