SHREVEPORT, LA - A recent state health inspection at Southern Oaks Nursing & Rehabilitation Center identified a significant medication error involving a resident with serious mental health conditions who did not receive their prescribed psychiatric medication at the proper frequency for nearly three weeks.
Psychiatric Medication Not Given as Ordered
The inspection, conducted on May 21, 2025, revealed that Resident #25, who has been diagnosed with bipolar disorder and paranoid schizophrenia, failed to receive their Risperdal medication twice daily as prescribed by their physician. Records showed that on May 2, 2025, the resident's doctor ordered an increase in Risperdal dosage from once daily to twice daily - a critical adjustment for managing psychiatric symptoms.
However, medication administration records from May 3 through May 20 documented that staff continued administering the medication only once per day at bedtime, despite the physician's new orders. This meant the resident went 18 days without receiving the full prescribed dosage of their antipsychotic medication.
When interviewed by inspectors, a Licensed Practical Nurse confirmed that "Resident #25 received Risperdal 1mg po at HS," acknowledging the once-daily administration. The Director of Nursing subsequently verified the medication error, confirming that the resident "had not received Risperdal 1mg 1 po BID as ordered on 05/02/2025."
Medical Implications of Missed Antipsychotic Doses
Risperdal (risperidone) is an atypical antipsychotic medication that works by balancing dopamine and serotonin levels in the brain. For individuals with bipolar disorder and schizophrenia, maintaining consistent therapeutic blood levels of this medication is essential for symptom control. When doses are missed or reduced, patients can experience a return of psychiatric symptoms within days.
The failure to administer the medication twice daily as prescribed represents a 50% reduction in the intended dose. This underdosing can lead to breakthrough symptoms including hallucinations, delusions, severe mood swings, agitation, and paranoia. For residents with paranoid schizophrenia specifically, inadequate medication levels may result in increased suspiciousness, social withdrawal, and potential aggressive behaviors stemming from paranoid thoughts.
Industry Standards for Medication Administration
Nursing facilities are required to follow strict protocols for medication management. Standard practice dictates that any change in physician orders must be immediately transcribed to the medication administration record and communicated to all nursing staff responsible for medication passes. Most facilities utilize a multi-step verification process: the receiving nurse documents the order change, pharmacy reviews and updates the medication system, and a second nurse verifies the change during the next medication pass.
The 18-day gap between the physician's order and the discovery of the error indicates multiple systemic failures. Each medication pass represents a missed opportunity to catch the discrepancy - with typically two to three different nurses administering medications during various shifts, this error should have been identified much sooner.
Systemic Concerns and Quality Assurance Failures
This medication error raises concerns about the facility's quality assurance processes. Medicare regulations require nursing homes to maintain systems that prevent significant medication errors, defined as errors that cause resident discomfort or jeopardize health and safety. The facility's own medication administration records clearly documented the continued once-daily administration, yet no staff member identified or corrected the discrepancy for over two weeks.
The error also suggests potential issues with the facility's communication between departments. When physicians change medication orders, there should be clear protocols for ensuring pharmacy services, nursing supervisors, and direct care staff are all aware of the modifications. The fact that this error affected a resident with serious psychiatric conditions - a population particularly vulnerable to medication changes - makes the oversight especially concerning.
Modern nursing facilities typically employ electronic medication administration systems with built-in alerts for order changes. These systems flag discrepancies between physician orders and scheduled medication passes. The prolonged nature of this error suggests either the absence of such safeguards or staff override of safety alerts without proper verification.
For families considering nursing home care for loved ones with psychiatric conditions, this case underscores the importance of regularly reviewing medication administration records and maintaining open communication with facility physicians and nursing staff about any medication changes.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Southern Oaks Nursing & Rehabilitation Center from 2025-05-21 including all violations, facility responses, and corrective action plans.
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