The resident, identified as R3, was admitted with multiple conditions including congestive heart failure, cognitive communication deficit, major depressive disorder, and osteoarthritis. On December 3, 2025, a nurse practitioner ordered Zoloft 25 mg to be given nightly at bedtime.
Registered nurse V10 received the order that afternoon and delegated it to the next shift. But when she spoke with R3's power of attorney, he declined the medication. "He verbalized his uncle has been verbalizing negative/depressive thoughts for years," progress notes from December 4 show. "POA does not want additional medications now."
V10 forgot to discontinue the order in the electronic medical record.
Licensed practical nurses began administering the Zoloft on December 5, unaware that consent had been refused. The medication continued nightly through December 17 — a total of 13 doses given without authorization.
The power of attorney discovered the unauthorized treatment during a care plan meeting on December 18. Progress notes from that day capture his anger: "POA became upset stating he declined this medication so it should not have been given. POA stated I do not want to attend these meetings any longer. These meetings are not effective, your staff just does the opposite of what I request."
Director of Nursing V2 confirmed the sequence of events to inspectors. "V10 did not discontinue the order for Zoloft," she said. "V10 forgot about it and the medication was still on the MAR and the LPN's gave the medication without consent."
The facility's own audit report shows the Zoloft order was finally discontinued on December 18, the same day as the confrontational care plan meeting. By then, R3 had received nearly two weeks of antidepressant medication that his family had specifically rejected.
Federal inspectors found the violation represented a failure to ensure residents are fully informed about their health status, care and treatments. The facility's own policy requires nursing staff to "obtain all consent for as required by regulation from the POA."
The case illustrates how communication breakdowns in nursing homes can override family wishes about medical treatment. While the registered nurse properly consulted the power of attorney before starting the medication, her failure to follow through on his refusal meant the resident received unwanted psychiatric medication for nearly two weeks.
The power of attorney's threat to stop attending care meetings suggests the incident damaged his relationship with the facility. His complaint that staff "does the opposite of what I request" points to broader concerns about whether his wishes as decision-maker were being respected.
The medication administration records show the Zoloft was given consistently each night from December 5 through December 17, indicating multiple nursing staff members administered doses without realizing consent had been withdrawn. The systematic nature of the error suggests the facility lacked adequate safeguards to prevent unauthorized medication administration.
R3's case was the only one reviewed by inspectors for medication consent issues, but it represented a complete breakdown in the facility's obligation to honor family healthcare decisions. The resident received psychiatric medication for depression despite his power of attorney's clear refusal based on his assessment that the symptoms had persisted for years without requiring pharmaceutical intervention.
The violation occurred just weeks before the New Year, when federal inspectors arrived following a complaint. The facility's failure to implement its own consent policies left R3 receiving unwanted treatment while his frustrated power of attorney considered abandoning his oversight role entirely.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sunny Hill Nursing Home of Will County from 2026-01-02 including all violations, facility responses, and corrective action plans.