The medication error happened because staff used an outdated medication list from May 22, 2024, during the admission process instead of the current list dated November 3, 2025, according to a December 30 state inspection.
Resident 1 was prescribed lisinopril 20 mg for blood pressure control upon admission, despite records clearly showing the drug was stopped on May 22, 2024, due to hyperkalemia. The condition occurs when potassium levels spike dangerously high, potentially interfering with heart rhythm and muscle function.
The facility also placed the resident on two other discontinued medications. Staff prescribed methimazole for hyperthyroidism even though the resident was actually being treated with levothyroxine for the opposite condition — hypothyroidism. They also ordered simvastatin for cholesterol despite it not appearing on the current medication list.
By November 11, 2025, the resident's provider ordered laboratory testing and directed that lisinopril be discontinued. The next morning's lab results showed the resident's potassium level had climbed to 5.2 mmol/L, above the normal range of 3.5-5.1 mmol/L.
The provider was notified of the elevated potassium level on November 12 at 12:21 PM and immediately ordered Kayexalate, a medication used to lower dangerously high potassium levels in the blood.
The Nursing Home Administrator confirmed during interviews on December 30 that staff had failed to follow facility policy for medication reconciliation. The administrator acknowledged that using the May medication list instead of the November update resulted in the resident receiving multiple discontinued drugs.
"The facility failed to reconcile medications in accordance with facility policy, resulting in Resident 1 receiving multiple discontinued medications, including lisinopril, which contributed to another episode of hyperkalemia," the administrator told inspectors.
The medication mix-up represented a fundamental breakdown in the admission process. When the referring facility transferred the resident, they provided an updated medication list from November 3, 2025. But Riverstreet Manor staff used a medication list that was more than five months old.
The conflicting thyroid medications posed another serious risk. Methimazole is used to treat overactive thyroid, while levothyroxine treats underactive thyroid. Giving both types of medication to the same patient could cause dangerous swings in thyroid hormone levels.
The blood pressure medication error was particularly concerning because the resident had already experienced hyperkalemia from lisinopril just months earlier. The referring facility's documentation clearly stated the drug was discontinued specifically because of elevated potassium levels.
Hyperkalemia can cause muscle weakness, irregular heartbeat, and in severe cases, cardiac arrest. The condition requires immediate medical intervention, which is why the provider ordered Kayexalate as soon as the lab results came back elevated.
The administrator confirmed that the medication reconciliation process was not completed as required by facility policy. This failure meant the resident was not protected from medication errors that could have been easily prevented by using the correct, current medication list.
State inspectors found the facility violated multiple Pennsylvania regulations governing resident care policies, nursing services, and pharmacy services. The violation was classified as causing minimal harm or potential for actual harm to few residents.
The case highlights how administrative failures during admission can have immediate medical consequences. A simple step — using the most recent medication list instead of an outdated one — could have prevented the resident from experiencing a second episode of the same dangerous condition that had already led to medication changes months earlier.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Riverstreet Manor from 2025-12-30 including all violations, facility responses, and corrective action plans.