DUARTE, CA - A California nursing home administered Parkinson's medication to a resident for months without properly documenting the diagnosis in medical records, creating potential safety risks during a critical medication trial period.
Missing Diagnosis Creates Documentation Gap
Monrovia Post Acute faced citations during a May 2025 inspection after regulators discovered that a resident receiving Sinemet, a medication for Parkinson's disease, did not have the diagnosis properly recorded in their comprehensive assessment records. The resident had been prescribed the medication since January 2025 following a neurologist consultation, yet the facility's Minimum Data Set (MDS) assessment failed to include Parkinson's disease under the neurological conditions section.
The 84-year-old resident, who had multiple complex medical conditions including dementia, diabetes, and heart irregularities, was observed by inspectors to have noticeable tremors in both upper extremities - a characteristic symptom of Parkinson's disease. Despite these visible symptoms and an active prescription for Sinemet, the facility's April 2025 assessment omitted the neurological diagnosis entirely.
Licensed Vocational Nurse 3, when questioned by inspectors, acknowledged the error, stating "the diagnosis was not coded in Resident 2's MDS dated [DATE], and the MDS was inaccurate." The nurse emphasized that "the correct resident's diagnosis was important; otherwise, Resident 2 could be taking medication that may result in an adverse medication event."
Critical Medication Monitoring Gaps
The documentation failure occurred during a particularly vulnerable period for the resident. According to the neurologist's consultation notes from January 2025, the resident was started on what medical professionals call a "Levodopa trial" - a diagnostic treatment approach used to determine if a patient's symptoms respond to Parkinson's medication.
The prescribing neurologist had specifically warned facility staff about potential complications, noting that "Levodopa may worsen or precipitate behavior disturbances" and instructing staff to "contact me right away if there are any concerns for adverse reactions." Despite these clear monitoring instructions, the facility never followed up with the neurologist after initiating the medication.
When contacted by inspectors, the neurologist confirmed he had only seen the resident one time and there was no follow-up by the facility, even though he indicated "follow-up on Resident 2's Levodopa trial could be done in a day or two after Resident 2 started taking Sinemet."
Medical Risks of Inadequate Monitoring
Sinemet contains levodopa and carbidopa, medications that require careful monitoring due to their potential for significant side effects. Medical protocols emphasize the importance of regular assessment during the initial treatment period, particularly for elderly patients with multiple medical conditions and cognitive impairment.
The medication can cause dyskinesia - abnormal, involuntary movements that can significantly impact a patient's quality of life and safety. Other potential adverse effects include confusion, hallucinations, and behavioral changes, which can be particularly problematic for residents with existing dementia.
For patients with multiple medical conditions like this resident, who had diabetes, heart rhythm disorders, and blood pressure issues, medication interactions and side effects require heightened vigilance. The combination of cognitive impairment and complex medical needs makes accurate diagnosis documentation essential for safe medication management.
Industry Standards and Best Practices
Federal regulations require nursing homes to maintain comprehensive and accurate resident assessments through the MDS system. These assessments serve multiple critical functions: they guide care planning, ensure appropriate staffing levels, and facilitate proper medication monitoring protocols.
The facility's own policies, revised in October 2023, explicitly state that "information in the MDS assessments will consistently reflect information in the progress notes, plans of care and resident observations." The policy also requires that assessments be completed by qualified staff members knowledgeable about each resident's condition.
Medication regimen reviews, conducted monthly by consultant pharmacists, are designed to identify exactly these types of monitoring gaps. However, the facility's pharmaceutical reviews from January through April 2025 failed to identify any irregularities with the Sinemet prescription, despite the missing diagnosis and lack of neurologist follow-up.
Additional Issues Identified
The inspection revealed the medication had been discontinued in May and then restarted without clear documentation of the reasoning. The resident's complex medical history, including recent blood clots in the arm and multiple psychiatric and neurological conditions, made proper diagnostic tracking even more critical for safe care coordination.
The case highlights broader concerns about medication management protocols and the importance of interdisciplinary communication in nursing home settings, particularly for residents with multiple chronic conditions requiring specialized monitoring.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Monrovia Post Acute from 2025-05-15 including all violations, facility responses, and corrective action plans.
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