Fairview Fellowship Home: Unnecessary Drug Concerns - OK
The incident at Fairview Fellowship Home For Senior Citizens involved a resident whose hydroxyzine dose had been reduced from 25 mg three times daily to twice daily after a pharmacist review on September 24. The physician agreed to the reduction and ordered the change.
But LPN #1, working through an agency, entered the medication order as three times daily instead of twice daily on September 25 at 7:11 p.m. She did this hours after the Director of Nursing had already correctly entered the physician's order for twice daily dosing earlier that same day.
The resident received four additional doses of hydroxyzine from September 25 through September 29 as a result of the nurse's unauthorized change.
When questioned about the error, LPN #1 told staff "they knew the doctor meant TID and not BID so that was why LPN #1 entered the order as TID," according to RN #1's account to inspectors. TID means three times daily, while BID means twice daily.
The medication error went undetected for four days. On September 29, RN #1 discovered the discrepancy while checking the resident's orders and immediately had the medication aide hold the medication. RN #1 then verified with the physician that the correct order was twice daily, not three times daily.
The error began with a routine medication review. On September 23, the facility's pharmacist had requested a gradual dose reduction of the resident's hydroxyzine, which was being given three times daily. The primary care physician agreed and ordered the change to twice daily on September 24.
The Director of Nursing entered the correct order into the resident's chart on September 25. But that evening, LPN #1 changed it back to three times daily without verifying the order with the physician or the Director of Nursing.
LPN #1 later told inspectors that medication aides had asked her to change the orders back to three times daily. She admitted she "changed the order for hydroxyzine 25 mg BID to TID without verifying the order was correct."
The facility's administrator confirmed that LPN #1 had called the physician and verified the order as twice daily, but then entered it incorrectly as three times daily. The administrator said this contradicted what the physician had actually ordered.
The Director of Nursing learned about the unauthorized order change on September 30, when RN #1 alerted her to the discrepancy in the resident's health record. The Director of Nursing confirmed that LPN #1 had changed the resident's order back to three times daily at 7:11 p.m. on September 25.
The facility banned LPN #1 from returning. The administrator stated that "LPN #1 was an agency staff and was not allowed to return to the facility due to the error." 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."
Hydroxyzine is an antihistamine commonly prescribed for anxiety and itching in elderly residents. The pharmacist's request for a gradual dose reduction suggests concern about the medication's effects on the resident.
The incident highlights the risks of agency staffing in nursing homes, where temporary workers may not fully understand facility protocols or physician orders. LPN #1's decision to override the physician's order based on her own interpretation of what the doctor "meant" violated basic medication administration protocols.
The resident received 25 mg of hydroxyzine four times more than prescribed over the four-day period. Each extra dose represented a 50 percent increase over the physician's intended daily dosage.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm to few residents.
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 physician agreed to the reduction and ordered the change.
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.