Benedictine Health Center: Seizure Medication Error - MN
The resident, identified as R15 in inspection documents, was hospitalized for seizures on October 20, 2025, and returned the same day with orders for Keppra 1000 mg twice daily. A nurse transcribed the order incorrectly as 100 mg twice daily.
For nearly a month, from October 21 through November 13, 2025, R15 received just one-tenth of his prescribed anti-seizure medication.
On November 13, R15 had another seizure. Staff sent him to the hospital for evaluation, where he was discharged the same day with instructions to continue the 1000 mg dose twice daily. Nobody at the facility caught the error.
The next day, R15's nurse practitioner called the facility after reviewing his emergency room visit. According to nurse manager RN-B, the NP had realized a medication error occurred. "According to the ED report he [R15] should have been getting 1000 mg twice a day and he is getting the liquid at the facility, but he is only getting 100 mg twice a day," a provider note from November 14 stated. The note added: "This possibly is why he was having breakthrough seizures."
RN-B received a verbal order correcting the dose to 1000 mg twice daily. She reported the error to the interim director of nursing and called the family.
She didn't know if anyone reported the medication error to state authorities.
They hadn't. During interviews on April 2, 2026, the administrator and the company's regional nurse told inspectors the transcription error went unreported "because it was not clear this caused harm to R15." Instead, they said, "the error was internally fixed and R15 was monitored for further seizure activity."
The facility's medication error policy, dated August 31, 2023, requires licensed staff to provide immediate care when errors occur and notify the attending provider and resident or resident representative. The policy makes no mention of reporting thresholds based on whether harm is "clear."
Multiple staff members described the facility's double-check system during inspector interviews. Health unit coordinator HUC explained that nurses write orders, she transcribes them into the computer, then returns the order to the nurse for accuracy verification. "All orders were always checked twice," she said.
Licensed practical nurse LPN-A said when residents return from hospitals, nurses fax orders to the pharmacy. RN-E described how nurses get orders, the HUC or a nurse enters them in the computer, then orders get verified by two people. "All orders were double checked," RN-E said.
RN-E also told inspectors she knew she had to report medication errors and complete paperwork following facility policy.
Despite these safeguards, R15's seizure medication order was transcribed wrong and remained wrong for 24 days. The error was discovered only when his nurse practitioner reviewed his second emergency room visit and connected his breakthrough seizures to the incorrect dose.
Federal inspectors classified this as a medication error violation affecting few residents with minimal harm or potential for actual harm. The inspection occurred April 3, 2026, more than four months after R15's breakthrough seizures and nearly five months after the original transcription error.
The facility's decision not to report the error to state authorities meant regulators learned about it only through their routine inspection process. By then, R15 had experienced weeks of inadequate seizure control and an additional hospitalization that his own medical provider linked to the dosing mistake.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Benedictine Health Center of Minneapolis from 2026-04-03 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Benedictine Health Center of Minneapolis
- Browse all MN nursing home inspections
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 14, 2026 · Our methodology
Benedictine Health Center Of Minneapolis in MINNEAPOLIS, MN was cited for violations during a health inspection on April 3, 2026.
A nurse transcribed the order incorrectly as 100 mg twice daily.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.
Frequently Asked Questions
- What happened at Benedictine Health Center Of Minneapolis?
- A nurse transcribed the order incorrectly as 100 mg twice daily.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in MINNEAPOLIS, MN, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from Benedictine Health Center Of Minneapolis or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 245266.
- Has this facility had violations before?
- To check Benedictine Health Center Of Minneapolis's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.