The violations involved Resident C, who has fibromyalgia, depression and chronic pain. A physician ordered oxycodone with acetaminophen 7.5 milligrams every four hours as needed for pain on June 20.
Throughout August, Qualified Medication Aide 10 gave the narcotic repeatedly during overnight shifts. The controlled drug record shows doses at midnight, 4 a.m. and 8 p.m. on multiple dates between July 31 and August 28.
But the resident's clinical record contained no assessment by a licensed nurse for any of these administrations. The controlled drug record also lacked the required co-signature from a licensed nurse authorizing each dose.
State regulations require specific steps before medication aides can give narcotic pain medications. A licensed nurse must assess the resident when the medication is requested and co-sign the controlled drug record, according to QMA 5, another medication aide interviewed by inspectors.
The facility's own policy document, titled Qualified Medication Aide Scope of Practice, spells out the requirements. Medication aides can only administer previously ordered as-needed medications "if authorization is obtained from the facility's licensed nurse on duty or on call."
When authorization is granted, the aide must document the resident's symptoms indicating need for the medication and the time symptoms occurred. The aide must also document that a licensed nurse was contacted, symptoms were described, and permission was granted to administer the medication, including the time of contact.
The policy requires getting permission each time symptoms occur. The resident's record must be co-signed by the licensed nurse who gave permission by the end of that nurse's shift.
None of these steps were followed for Resident C's narcotic doses in August.
The pattern shows the medication aide giving oxycodone during consecutive overnight shifts. On August 1, the aide administered doses at midnight and 4 a.m. On August 10, three doses were given: 12:30 a.m., 4 a.m. and 8 p.m. On August 14, doses were recorded at midnight, 4 a.m. and 8 p.m.
The violations continued through the end of the month. On August 27, a dose was given at 8 p.m., followed by doses at midnight and 4 a.m. on August 28.
Each administration violated both state regulations and facility policy by proceeding without nurse assessment or authorization.
The Director of Nursing provided inspectors with an undated copy of the facility's medication aide scope of practice document during the September 3 inspection. The document clearly prohibits the actions documented in Resident C's record.
Inspectors classified the violation as causing minimal harm or potential for actual harm. The citation affects few residents, according to the inspection report.
The failure represents a breakdown in medication safety protocols designed to protect vulnerable residents from inappropriate narcotic administration. Licensed nurses are required to assess residents before narcotic doses because they have training to evaluate pain levels, potential side effects, and drug interactions that medication aides lack.
Westminster Village Kentuckiana operates at 2210 Greentree North in Clarksville. The facility must submit a plan of correction addressing how it will prevent similar violations.
The inspection was conducted in response to a complaint filed against the facility. State inspectors completed their review on September 4, documenting the medication administration failures that occurred throughout August.
Resident C received the unauthorized narcotic doses while experiencing fibromyalgia pain, a chronic condition that can cause widespread musculoskeletal discomfort. The resident's care plan included the as-needed oxycodone prescription to manage pain episodes, but facility staff failed to follow required safety protocols when administering the controlled substance.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Westminster Village Kentuckiana from 2025-09-04 including all violations, facility responses, and corrective action plans.
Additional Resources
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