Fairview Fellowship Home: Psychotropic Drug Violation - OK
The incident at Fairview Fellowship Home for Senior Citizens began September 24, 2025, when a physician agreed to reduce Resident #8's hydroxyzine dose from 25 milligrams three times daily to twice daily following a pharmacist's recommendation for gradual dose reduction.
The Director of Nursing entered the new order for hydroxyzine 25 mg twice daily on September 25. But later that evening at 7:11 p.m., LPN #1 changed the order back to three times daily without physician verification.
When RN #1 discovered the unauthorized change on September 29, they held the medication and contacted the physician to verify the correct dosage. The physician confirmed the order should remain twice daily, not three times.
LPN #1 told RN #1 "they knew the doctor meant TID and not BID so that was why LPN #1 entered the order as TID," according to the inspection report. TID means three times daily; BID means twice daily.
The unauthorized change meant Resident #8 received hydroxyzine 25 mg on September 26, 27, 28, and 29 that should not have been administered under the physician's reduced dosing order.
During interviews with inspectors, LPN #1 acknowledged the error. "LPN #1 stated they changed the order for hydroxyzine 25 mg BID to TID without verifying the order was correct," investigators found. The nurse admitted putting "the order in as hydroxyzine 25 mg TID when it should have been BID."
The medication error stemmed from confusion during the order entry process. The administrator explained that LPN #1 had called the physician to verify the order and was told it should be twice daily, but then entered it as three times daily anyway.
"The administrator stated LPN #1 called the physician and verified the order as BID but LPN #1 put the order in as TID which was not what the physician had ordered," the report states.
The facility's response was swift. The administrator banned the agency nurse from returning to the facility due to the medication error.
"The administrator stated LPN #1 was an agency staff and was not allowed to return to the facility due to the error," inspectors documented. The Director of Nursing confirmed that "LPN #1 was placed on a do not return from the agency as a result of the medication order error."
The medication review that triggered the dose reduction had been conducted by the pharmacist on September 23. The pharmacist recommended gradually reducing the hydroxyzine dose, and the primary care physician agreed the following day.
Hydroxyzine is an antihistamine commonly prescribed for anxiety and itching in elderly patients. The medication can cause drowsiness, confusion, and increased fall risk, particularly at higher doses.
The incident revealed gaps in the facility's medication order verification process. Despite the Director of Nursing properly entering the physician's reduced dose order on September 25, an agency nurse was able to change it hours later without proper authorization.
RN #1 discovered the problem four days later during a routine order review. "RN #1 stated on 09/29/25, they checked Resident #8's orders and saw LPN #1 changed Resident #8's orders on 09/25/25 around 7:00 p.m., to hydroxyzine 25 mg TID after the DON had changed the order on 09/25/25 earlier in the day."
The medication aide who would have administered the doses followed proper protocol by holding the medication once RN #1 identified the discrepancy and verified the correct order with the physician.
Federal inspectors found the facility failed to ensure medications were administered as prescribed by the physician, violating regulations requiring accurate medication administration. The violation was classified as causing minimal harm with few residents affected.
The incident occurred despite multiple staff members being involved in the medication review and ordering process, highlighting how individual decisions to override established orders can compromise patient safety even within functioning systems.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Fairview Fellowship Home For Senior Citizens, Inc from 2025-11-21 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
Fairview Fellowship Home For Senior Citizens, Inc in Fairview, OK was cited for violations during a health inspection on November 21, 2025.
The Director of Nursing entered the new order for hydroxyzine 25 mg twice daily on September 25.
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.