Federal inspectors found the medication errors at Rivercrest Post Acute placed residents at risk for adverse side effects during a November complaint investigation.
Resident 2 had been recovering from surgery and a motor vehicle accident that left multiple fractures when the oxycodone overdose occurred in April. The resident's care plan noted ongoing pain from the recent trauma, with interventions including administering medications as ordered by physicians.
An April 8 physician order specified that Resident 2 could receive oxycodone in 5-milligram or 10-milligram doses every four hours as needed for pain. The order explicitly stated the medication was not to exceed 40 milligrams daily.
On April 23, Staff 5, a licensed practical nurse, signed out doses that totaled 50 milligrams of oxycodone for Resident 2 in a single day. A progress note the following day documented that Staff 5 had noted the excessive dosing, and both the resident and the on-call provider were notified. The resident was placed on alert status for monitoring.
A medication error report filed April 24 confirmed Staff 5 had administered 50 milligrams when the daily limit was 40 milligrams.
When inspectors interviewed Staff 5 on November 13, the nurse stated she recalled the resident had "an odd order related to pain medication." However, Staff 5 could not recall the specific medication error and was unable to provide additional information about what had happened.
The facility's director of nursing acknowledged the excessive oxycodone administration when interviewed by inspectors November 14.
A separate medication error involved Resident 22, who had been living at the facility since 2023 with a diagnosis of depression. On December 20, 2024, Staff 15, another licensed practical nurse, approached Resident 22 with medications but called out the wrong name.
Resident 22 did not hear the incorrect name and took the medication as offered. The resident received the roommate's morning medication, which included 60 milligrams of duloxetine, an antidepressant. The provider was notified and the resident was placed on alert for adverse side effects.
The medication error report from that day confirmed Resident 22 had received the roommate's duloxetine dose. When asked how they felt, Resident 22 indicated feeling fine.
Staff 22, who was working for a staffing agency and had only worked one or two shifts at the facility, was involved in the December incident. When inspectors interviewed her November 18, she explained her approach to medication administration.
Staff 22 stated that on the day of the incident, she asked Resident 22 if this was the roommate's name, and the resident said yes. She told the resident she had medication for them, and the resident agreed and took it.
The error became apparent when Staff 22 went to give medication to the actual roommate and realized she had given Resident 22 the wrong medication.
Staff 22 explained her general practice when working with unfamiliar residents. If she was not familiar with a resident and no picture was available, she would ask other staff where she could find the specific resident. She acknowledged the medication error had occurred.
The facility administrator also acknowledged the medication error involving Resident 22 when interviewed by inspectors November 18.
Both incidents represented failures to follow physician orders and proper medication administration procedures. The oxycodone overdose exceeded the maximum daily dose prescribed by 25 percent, while the antidepressant error meant one resident received a psychiatric medication not prescribed for them while missing their own prescribed medications.
Federal inspectors classified both errors as creating minimal harm or potential for actual harm to residents. The findings were part of a complaint investigation that examined medication practices affecting few residents at the facility.
The medication errors occurred despite care plans and physician orders designed to ensure proper dosing and administration. Staff 5's inability to recall details of the oxycodone overdose months later, and Staff 22's reliance on asking residents to confirm names rather than using more reliable identification methods, highlighted gaps in medication safety protocols.
Both residents were placed on alert status for monitoring after their respective medication errors, but the inspection report did not document any adverse effects that resulted from either incident.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Rivercrest Post Acute from 2025-11-19 including all violations, facility responses, and corrective action plans.