HospitalInspections.org

Based on record review, interview, and facility policy review, the facility failed to administer medication, per federal and state laws and regulations, and in accordance with facility-approved policies and procedures for 1 (Patient #1) of 3 patients sampled.

The findings include:

1. A review of the patient's medical record revealed that Patient #1 was admitted to the facility from 11/09/2025 to 11/14/2025. Patient #1 had a diagnosis of Parkinson's disease with dyskinesia (uncontrolled muscle movements). Patient #1 was prescribed Carbidopa/Levodopa (a medication for Parkinson's disease) three times per day, at 7:00 AM, 12:00 PM, and 6:30 PM. "On November 12, 13, and 14, 2025, Carbidopa/Levodopa was not administered at the prescribed times, with the medication being given up to two hours and thirty minutes late. An article published in the National Library of Medicine states, "When [Parkinson's] medications are not administered on time and according to the patient's unique schedule, patients may experience an immediate increase in symptoms. Delaying medications by more than one hour, for example, can cause patients with Parkinson's disease to experience worsening tremors [shaking], increased rigidity [muscle stiffness], loss of balance, confusion, agitation, and difficulty communicating." https://pubmed.ncbi.nlm.nih.gov/29290668/

On 11/24/2025, at 12:40 PM, an interview was conducted with the Chief Nursing Officer. She confirmed that Carbidopa/Levodopa was a time critical medication and should have been administered 30 minutes before or 30 minutes after the time that it was ordered, as per the facility policy.

A review of the facility policy titled "Medication Administration" with a last approved date of 08/2025, was conducted. On page 3, the policy stated, "III. Time-critical scheduled medications are those for which an early or late administration of greater than thirty minutes might cause harm or have significant, negative impact on the intended therapeutic or pharmacological effect. The following medications must be administered within thirty minutes before or after their scheduled dosing time: Anti-Parkinson agent, given more frequently than once daily: Carbidopa/Levodopa."