LAKE WACCAMAW, NC - State inspectors documented serious medication management failures at Premier Living and Rehab Center during a July 2024 complaint investigation, finding that healthcare providers were not notified when residents missed critical pain medications or received incorrect antibiotics.
Critical Pain Medication Doses Missed Without Physician Notification
The inspection revealed that two residents went without their prescribed nerve pain medication for extended periods while physicians remained uninformed of the lapses. Gabapentin, the medication involved, requires careful management as it affects the central nervous system and cannot be discontinued suddenly without medical supervision.
One resident prescribed gabapentin 800 milligrams four times daily missed 21 consecutive doses between May 8 and May 13, 2024. During this period, the resident reported constant pain reaching the maximum level of 10 on the standard pain scale, along with numbness in the legs and muscle spasms. Despite these significant symptoms, facility staff did not contact the prescribing physician to report either the missed medications or the resident's deteriorating condition.
A second resident experienced similar issues when 14 doses of gabapentin 800 milligrams twice daily went unadministered between May 10 and May 17, 2024. This resident reported multiple complications including sleep disturbances, increased anxiety, irritability, nausea, and pain severe enough to prevent participation in normal daily activities.
Gabapentin works by modifying nerve signal transmission in the brain and nervous system. The medication builds up in the system over time to achieve therapeutic levels, and sudden discontinuation can trigger withdrawal symptoms including increased pain sensitivity, anxiety, sweating, and in severe cases, seizures. Medical protocols require tapering the medication gradually under physician supervision rather than abrupt cessation.
The failure to notify physicians represents a breakdown in the communication chain essential for patient safety. When prescribed medications are not administered as ordered, physicians must be informed immediately so they can assess the situation, provide alternative pain management strategies, or adjust the treatment plan. Without this notification, physicians cannot make informed clinical decisions about their patients' care.
Wrong Antibiotic Administered After Hospital Discharge
Inspectors also identified a medication substitution error affecting a third resident. Following hospital discharge, a physician prescribed Augmentin (amoxicillin-clavulanate 875 mg-125 mg), a combination antibiotic containing two active ingredients. However, facility staff administered plain amoxicillin 875 mg instead for 14 doses without informing the physician of the substitution.
While both medications belong to the penicillin family, they are not interchangeable. Augmentin contains clavulanate, an enzyme inhibitor that prevents certain bacteria from developing resistance to the amoxicillin component. The combination medication is specifically prescribed when doctors determine that plain amoxicillin would be insufficient to treat the infection.
By substituting a single-ingredient antibiotic for the prescribed combination therapy, staff potentially compromised the resident's treatment. The infection may not have responded adequately to the weaker medication, potentially leading to treatment failure, prolonged infection, or development of antibiotic-resistant bacteria. Standard pharmaceutical protocols prohibit such substitutions without explicit physician authorization.
Medical Implications of Notification Failures
Healthcare facilities operate under established protocols requiring immediate physician notification when medications cannot be administered as prescribed. These protocols exist because physicians make treatment decisions based on the assumption that prescribed medications are being given correctly. When this assumption proves false and physicians remain uninformed, they cannot respond appropriately to changes in patient condition.
The documentation of pain scores reaching maximum levels should have triggered multiple intervention protocols beyond medication administration. Pain management standards require reassessment and physician notification when pain remains uncontrolled, particularly at severe levels. The combination of missed medications and inadequate pain relief represented a serious compromise in quality of care.
For antibiotic therapy, completing the full prescribed course with the correct medication is critical for infection resolution and preventing antibiotic resistance. The substitution of a different antibiotic without physician knowledge undermined the treatment plan developed during the hospital stay.
Additional Issues Identified
The inspection found these medication management failures affected three of the ten residents whose records were reviewed for physician notification practices, suggesting systemic rather than isolated problems. State surveyors classified the findings as immediate jeopardy to resident health or safety, the most serious category of violation, indicating the deficient practices posed a likelihood of serious injury or harm.
The facility received citations under federal regulation F580, which requires skilled nursing facilities to notify physicians of significant changes in resident condition, medication errors, and other incidents that could affect resident health and safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Premier Living and Rehab Center from 2024-07-02 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.