Home of the Innocents: Care Quality Failures - KY
The resident, identified as R40, had been prescribed Aripiprazole, an antipsychotic medication. When doctors discontinued the drug, facility staff made a phone call to the school but never completed the mandatory forms to officially communicate the medication change.
R40 received the first dose of Aripiprazole on August 7, 2025, his first day of school. The medication was discontinued at the facility on August 15, but the child had been receiving doses at school throughout that entire period.
The Resident Education Nurse Coordinator told inspectors on September 11 that she called and spoke with a nurse at R40's school to verbally discontinue the medication order. When questioned about the proper process for communicating medication changes to schools, she acknowledged there was a school form that was supposed to be completed and faxed or emailed.
She admitted the form had not been completed for the discontinuation of R40's Aripiprazole medication.
The facility sometimes relied on verbal orders to schools, she said, despite having written policies requiring specific documentation.
The Director of Support Services explained the medication process involved two forms during her September 11 interview. The School Medication Order Form, also called the Monthly School Medication Order Form, was supposed to be scanned to the pharmacy. The school Permission Form for Prescribed or Over the Counter Drugs was to be faxed or emailed to the school nurse.
She said she personally audited residents' medications to ensure accuracy at both the pharmacy and the school.
But the audit system failed to catch R40's case.
The Quality Assurance Nurse revealed during a September 12 interview that the facility's quality improvement team had already reviewed a root cause analysis for R40's medication error in their August meeting. The team had identified failures in the facility's process.
When asked what could happen when medication changes aren't properly communicated, she was direct about the stakes.
There could be a negative outcome if a resident continued receiving a discontinued medication, she said, such as an allergic reaction or even a fatal event.
The Director of Nursing reinforced those concerns during her September 12 interview. Orders were supposed to be checked daily, she said, and medication changes should be communicated to both the pharmacy and the school within 24 hours of any changes.
The potential for a negative outcome involving a resident receiving a discontinued medication could include overdose, or even death, she told inspectors.
The Administrator provided the clearest picture of what went wrong during her September 13 interview. When a medication order was changed, the Nursing Education Coordinator was expected to receive the order change information and fill out the correct school forms.
The Nursing Education Coordinator was supposed to send the order change information via email or fax to both the school and the facility's contracted pharmacy.
"The breakdown was that when the medication was changed, the double check did not occur, and the form was not filled out and the change was not communicated to the school," the Administrator said.
She acknowledged the severity of the potential consequences. The potential outcome of not communicating medication order changes could be serious injury up to death for a client receiving a discontinued medication, she told inspectors.
The inspection found that Home of the Innocents had established policies requiring proper documentation and communication of medication changes. But those policies weren't followed in R40's case.
The facility's own quality assurance process had already flagged this as a systemic failure, not just an isolated mistake. The August quality improvement meeting had identified problems with the medication communication process itself.
Despite having a Director of Support Services who personally audited medications for accuracy, and despite having a 24-hour requirement for communicating changes, the system broke down completely for R40.
The child received Aripiprazole for eight consecutive school days after it had been discontinued at the facility. For more than a week, two different medical settings were operating under completely different medication orders for the same patient.
The verbal phone call that the Resident Education Nurse Coordinator made to the school was meaningless without the required documentation. Schools need official forms to change medication protocols, not informal conversations.
The facility's acknowledgment that verbal orders to schools sometimes substituted for proper paperwork suggests this wasn't the first time the documentation requirements had been bypassed.
But the consequences of that informal approach became clear with R40's case. A discontinued psychiatric medication continued to be administered to a child for over a week because nursing staff didn't complete a form.
The Director of Nursing's statement that medication changes should be communicated within 24 hours makes the eight-day delay even more significant. The facility missed its own deadline by more than a week.
Home of the Innocents serves vulnerable children who depend entirely on staff to manage their medical care properly. When those children attend school, the facility becomes responsible for coordinating care across two locations.
R40's case revealed how that coordination can fail catastrophically. The child was caught between two medical systems that weren't communicating effectively, continuing to receive a medication that doctors had determined was no longer appropriate.
The Administrator's admission that the double-check system failed points to broader problems with the facility's medication management protocols. Quality assurance processes are supposed to catch these errors before they reach patients.
Instead, R40 continued receiving discontinued medication until he was hospitalized on August 15. Only then did the school stop administering the Aripiprazole.
The inspection found minimal harm occurred, but facility staff were clear about what could have happened. Multiple administrators used the word "death" when describing potential outcomes of continued medication errors.
For eight days, R40 received a psychiatric medication that his doctors had decided to discontinue, while facility staff failed to complete basic paperwork that could have prevented the error.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Home of the Innocents from 2025-09-13 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 20, 2026 · Our methodology
Home of the Innocents in Louisville, KY was cited for violations during a health inspection on September 13, 2025.
The resident, identified as R40, had been prescribed Aripiprazole, an antipsychotic medication.
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.