Life Care Center of Puyallup: Wrong Meds Given - WA
Staff H, an LPN, administered plain senna 8.6 mg to Resident 98 on April 10, despite the medication order calling for a senna-docusate sodium combination tablet. The nurse pulled the wrong bottle from the medication cart's top drawer and placed a single tablet in the medication cup without checking the label against the written order.
When inspectors asked Staff H to show them the bottle used for the dosing at 10:40 AM, the nurse re-read the medication administration record and immediately recognized the mistake. The resident's order specified senna-docusate sodium 8.6mg-50mg, but Staff H had given only senna 8.6mg.
Resident 98, who has cerebral palsy and is incontinent of both bowel and bladder, depends on staff for toileting, bed mobility, and transfers. The resident has both short-term and long-term memory problems and requires the combination medication twice daily for constipation management.
The medication error occurred during the same inspection that revealed systematic failures in monitoring residents' bowel movements before administering stool softeners.
Staff AA failed to check whether Resident 43 should receive a scheduled stool softener on the morning of April 10, despite the resident having loose stool at 5:18 AM. The nursing assistant pulled up the facility's alert dashboard but didn't see Resident 43 listed for loose stool monitoring.
A joint review with inspectors showed Resident 43's bowel record clearly documented the loose stool episode in the facility's computer system under the TASK tab. Staff AA acknowledged not knowing how to access bowel and bladder records in the system and admitted failing to hold the stool softener as required.
The facility's own protocol requires nurses to hold stool softener medications after any loose stool episode and monitor residents on an alert list until the condition resolves. Staff G, the LPN and Unit Care Coordinator, confirmed this policy during an interview, explaining that nurses must review each resident's daily bowel record under Question 3 of the TASK tab to evaluate stool consistency.
Staff G also described proper procedures for handling medication discrepancies, stating that prescription labels should match current orders, and when they don't, nurses should clarify orders and note corrections on medication cards until updated labels arrive.
The medication administration error represents a basic failure in the five rights of medication administration. Staff H had the correct resident and the correct time, but failed to verify the right medication, right dose, and right route before administration.
Both violations occurred within hours of each other during the same inspection day, suggesting broader systemic problems with medication management and bowel care protocols at the facility.
The cerebral palsy resident who received the wrong medication requires precise bowel management due to their underlying neurological condition and complete dependence on staff for basic care needs. Cerebral palsy affects muscle control due to brain changes during development, making proper medication administration critical for managing secondary complications like constipation.
Staff AA's inability to navigate the computer system to check bowel records before medication administration raises questions about training adequacy and system familiarity among nursing staff.
The facility's alert system failed to prevent both incidents. Resident 43 should have appeared on the loose stool alert list, and Staff H should have caught the medication discrepancy through standard verification procedures before administration.
Federal inspectors documented these failures as part of a broader review of medication administration practices at the 511 10th Avenue Southeast facility. Both incidents involved basic nursing responsibilities that directly affect resident safety and care quality.
The errors occurred despite established policies requiring bowel monitoring and medication verification, indicating gaps between written procedures and actual nursing practice at Life Care Center of Puyallup.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Life Care Center of Puyallup from 2026-04-10 including all violations, facility responses, and corrective action plans.
Additional Resources
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: August 4, 2026 · Our methodology
LIFE CARE CENTER OF PUYALLUP in PUYALLUP, WA was cited for violations during a health inspection on April 10, 2026.
The resident's order specified senna-docusate sodium 8.6mg-50mg, but Staff H had given only senna 8.6mg.
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.