Shawnee Care Center: Wrong Drug Dose for 11 Days - OK
The resident at Shawnee Care Center continued receiving 20 mg of olanzapine daily from July 8 through July 18, even though a physician had ordered the dose reduced to 15 mg on July 7. The medication error wasn't discovered until July 19, when someone finally noticed the discrepancy.
Federal inspectors who visited the facility in August found that 39 residents were taking psychotropic medications. They reviewed three cases and found the dosing error in one.
The resident involved has bipolar disorder and recurrent depressive disorders, according to medical records. A quarterly assessment from July 7 showed the person was moderately cognitively impaired with a cognitive score of 11. The assessment noted no symptoms of depression or behavioral issues, despite receiving both antipsychotic and antidepressant medications.
The error began with what should have been a routine medication adjustment. A pharmacist conducting a monthly review on July 1 recommended gradually reducing the resident's olanzapine from 20 mg daily. The physician agreed and issued orders on July 7 to discontinue the 20 mg dose and start 15 mg daily.
But the certified medication aide, identified as CMA #1, never noticed the change.
When inspectors interviewed CMA #1 on August 11, she admitted she "had not realized the physician order had changed from 20 mg daily to 15 mg daily on 07/07/25 and continued to give the 20 mg pill until the error was noticed on 07/19/25."
The aide told inspectors she "should have verified the dosage shown on the physician order in the medical record with the dosage on the pill card prior to administration."
A pill blister card dated July 7 contained a 30-day supply of the new 15 mg tablets. The first dose from that card wasn't given until July 19 — 12 days after it arrived. Six tablets remained in the card when inspectors examined it in August.
The facility's director of nursing investigated after being notified of the possible medication error on July 19. She confirmed that the resident "continued to receive olanzapine 20 mg daily until the medication error was verified on 07/19/25."
The director told inspectors that "CMA #1 should have verified the correct dosage on the pill card with the physician order prior to administration."
A medication error report filed on July 19 documented the mistake. It noted that the aide "was unaware the dosage had changed and continued to administer 20 mg daily until the error was noticed." The report stated there were "no apparent effects as an outcome" for the resident.
The dosage change was part of a gradual dose reduction recommended by the facility's consulting pharmacist. Such reductions are required under federal regulations when residents no longer need the full strength of psychotropic medications, particularly antipsychotics like olanzapine.
Olanzapine is used to treat schizophrenia and bipolar disorder. The difference between 20 mg and 15 mg represents a 25 percent higher dose than prescribed. While the facility reported no apparent effects on the resident, the medication has significant side effects including weight gain, diabetes risk, and movement disorders.
The inspection found the facility failed to ensure the resident's drug regimen was free from unnecessary drugs, specifically because the gradual dose reduction ordered by the physician wasn't implemented when directed.
Federal inspectors classified this as minimal harm or potential for actual harm. The violation affected some residents at the 39-bed facility.
The error illustrates a basic breakdown in medication administration protocols. Nursing homes are required to have systems ensuring residents receive the right medication, in the right dose, at the right time. This includes verifying physician orders against what's actually being administered.
For 11 days, this resident received a stronger dose of a powerful psychiatric medication than their doctor intended. The aide responsible continued following an outdated order, never checking whether new instructions had been issued.
The facility completed its investigation on July 19, the same day the error was discovered. But by then, the resident had already received nearly two weeks of incorrect medication — a span that could have been avoided with basic verification procedures that the aide acknowledged she should have followed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Shawnee Care Center from 2025-08-13 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 13, 2026 · Our methodology
Shawnee Care Center in Shawnee, OK was cited for violations during a health inspection on August 13, 2025.
The medication error wasn't discovered until July 19, when someone finally noticed the discrepancy.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.
Frequently Asked Questions
- What happened at Shawnee Care Center?
- The medication error wasn't discovered until July 19, when someone finally noticed the discrepancy.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in Shawnee, OK, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from Shawnee Care Center or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 375246.
- Has this facility had violations before?
- To check Shawnee Care Center's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.