Federal inspectors watched Hammond-Whiting Care Center staff administer Lokelma, a powdered medication for dangerously high potassium levels, to Resident E on two consecutive days in September. Both times, nurses handed her the mixture without explanation and instructed her to finish it despite her obvious distress.
On September 15 at 9:22 a.m., RN 1 prepared the powdered Lokelma in water and handed it to Resident E. The resident immediately began gagging on the mixture and complained about how bad it tasted. She indicated she did not want to finish drinking it.
RN 1 instructed her to drink the rest of the medication anyway. The nurse provided no information about what the medication was or why completing the full dose was medically necessary.
The scene repeated the next morning. At 9:28 a.m. on September 16, LPN 1 prepared the same powdered medication for Resident E and handed it to her without explanation. The resident struggled to drink the medication and started to cry because of the poor taste.
LPN 1 added more water to the mixture and instructed the resident to try and finish the medication drink. When inspectors interviewed LPN 1 immediately afterward, the nurse acknowledged that the resident did not like the way it tasted and would ask for more water.
Neither nurse informed Resident E that she was taking Lokelma, a medication specifically prescribed to treat high potassium levels that can cause dangerous heart rhythm problems if left untreated.
Resident E's medical record showed she had been admitted with multiple health conditions including high blood pressure, diabetes, and Bell's palsy. Her admission assessment from May 29 indicated she was moderately impaired for daily decision making, meaning she needed additional support to understand her care but was still capable of participating in treatment decisions.
A physician's order from August 27 directed staff to administer one packet of Lokelma once daily specifically for high potassium. The medication is designed to bind excess potassium in the intestines and remove it from the body, preventing potentially fatal cardiac complications.
The facility's own medication administration policy required staff to follow the "10 rights of medication administration," including the "Right Education and Information." This standard specifically directed staff to "provide enough knowledge to the resident of what drug he/she would be taking."
When inspectors interviewed the Assistant Director of Nursing on September 16, she confirmed that nurses and qualified medication aides should inform residents what medication they were receiving before administering it. This expectation aligned with federal regulations requiring facilities to ensure residents are fully informed about their health status, care and treatments.
The violation occurred despite Resident E's demonstrated ability to communicate her preferences and discomfort. She clearly expressed that the medication tasted bad and that she did not want to finish it, indicating she could engage in discussions about her care if staff had provided the necessary information.
Federal regulations require nursing homes to respect residents' rights to participate in their own care decisions. This includes receiving adequate information about medications, their purposes, and potential side effects before administration. The requirement becomes especially critical when residents express reluctance or distress about taking prescribed treatments.
The inspection found that Hammond-Whiting Care Center failed to meet this basic standard of informed care. Staff treated medication administration as a task to complete rather than an opportunity to educate and engage Resident E in her treatment plan.
Lokelma's manufacturer specifically notes that the medication has an unpalatable taste and recommends mixing it with water or soft foods to improve palatability. More importantly, patient education materials emphasize explaining to patients why completing the full dose is essential for the medication's effectiveness in removing dangerous potassium levels.
The facility's violation affected Resident E's fundamental right to understand her medical care. Without knowing she was taking a medication to prevent potentially life-threatening complications from high potassium, she could not make informed decisions about her treatment or understand why enduring the unpleasant taste was medically necessary.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, but noted it represented a failure in the facility's basic obligation to keep residents informed about their care. The citation was issued following a complaint investigation at the 114th Street facility.
The incident highlighted a broader breakdown in communication between nursing staff and residents about essential medical treatments, particularly affecting a resident whose cognitive impairment required additional support rather than less information about her care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hammond-whiting Care Center from 2025-09-16 including all violations, facility responses, and corrective action plans.