Terrell Healthcare: Antipsychotic Given Without Consent - TX
Resident #9 at Terrell Healthcare Center began receiving Olanzapine on January 25 for hallucinations. The facility didn't obtain his signed consent form until April 3 — the same day inspectors arrived to review his records.
The resident has major depressive disorder and hallucinations but maintained full cognitive capacity throughout his stay. His admission assessment showed he "made himself understood and understood others" with a BIMS cognitive score of 15, indicating intact mental function.
Staff administered the 5-milligram tablets twice daily at 8 a.m. and 8 p.m. medication passes since January 25, inspection records show. When inspectors accessed his electronic medical record on April 2, no consent form existed.
The facility's own pharmaceutical review on January 31 flagged the problem. The pharmacist's recommendation stated: "Please ensure signed consent form is scanned into PCC for the following medication: Olanzapine (on Texas form 3713)."
Nobody acted on that recommendation for more than two months.
On April 3 at 5 p.m. — hours after inspectors began reviewing records — a Texas Health and Human Services Form 3713 suddenly appeared in the resident's file. The consent form bore that day's date and signatures from both Resident #9 and the medical director.
The Executive Director told inspectors on April 2 that "all consents should be in the EMR." She said the Assistant Director of Nursing and Director of Nursing were responsible for ensuring medication consents were completed and uploaded before administration.
"It was important for residents to be informed of the side effects of the medications, and have the right to chose to take it," the Executive Director said.
The Director of Nursing acknowledged her responsibility the next day. She told inspectors nurses were responsible for getting proper consents before administering medication, and she was responsible for monitoring charts to ensure necessary consents were present.
"It was important to obtain the informed consent so residents were informed of risks versus benefits," the DON said.
The Administrator echoed this understanding, stating he expected all consents to be obtained prior to administering medications that require one. He said it was the ADON and DON's responsibility to ensure consents are obtained.
"It was important to obtain consent prior to administration because a resident should know about the side effects and be able to make the choice to take it or not," the Administrator said.
Yet none of these administrators ensured Resident #9 received information about Olanzapine's risks before staff began giving it to him twice daily.
Olanzapine carries significant side effects and a black box warning from the Food and Drug Administration. The antipsychotic can cause drowsiness, weight gain, increased blood sugar, and movement disorders. In elderly patients with dementia, it increases risk of death.
The facility's own policy, last reviewed in June 2025, requires informed consent before initiating psychotropic medications. The policy states all residents have "full rights to participate or refuse treatment" and must be notified of their right to accept or decline medication.
"The risk and benefits should be clearly explained," the policy reads. "Consent needs to be completed and signed by the Resident or Responsible party. Explain the medication, why it is administered, what are side effects, and black box warning."
Staff violated this policy for 69 days while administering Olanzapine to Resident #9.
The inspection found the facility failed to ensure residents had the right to be informed of and participate in their treatment. Inspectors reviewed consent procedures for six residents and found violations affecting Resident #9.
Federal inspectors determined the violation placed the resident at risk for unnecessary chemical restraint, adverse side effects, and violation of his rights to make informed decisions about his care and treatment.
The timing of the consent form's appearance — the same day inspectors reviewed records — suggests facility staff scrambled to create documentation only after discovering the federal review.
Resident #9 spent more than two months receiving a psychiatric medication without understanding its risks or having the opportunity to refuse treatment. Despite his intact cognitive abilities and clear communication skills, nobody provided him with information about Olanzapine's potential side effects or obtained his informed agreement to the treatment plan.
The facility's pharmaceutical consultant had identified the missing consent in January. The Executive Director, DON, and Administrator all understood the importance of obtaining consent before medication administration. Yet Resident #9 continued receiving twice-daily doses of Olanzapine without his informed agreement until federal inspectors arrived to review his care.
The violation occurred despite multiple layers of oversight that should have caught the missing consent. The pharmacist flagged it. The DON was supposed to monitor charts. The ADON shared responsibility for ensuring consents. The Executive Director expected all consents to be in the electronic medical record.
All of these safeguards failed Resident #9, who received a powerful psychiatric medication for more than two months without knowing what it was, why he was getting it, or what risks it posed to his health.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Terrell Healthcare Center from 2026-04-03 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 14, 2026 · Our methodology
Terrell Healthcare Center in Terrell, TX was cited for violations during a health inspection on April 3, 2026.
Resident #9 at Terrell Healthcare Center began receiving Olanzapine on January 25 for hallucinations.
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.
Frequently Asked Questions
- What happened at Terrell Healthcare Center?
- Resident #9 at Terrell Healthcare Center began receiving Olanzapine on January 25 for hallucinations.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in Terrell, TX, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from Terrell Healthcare Center or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 675879.
- Has this facility had violations before?
- To check Terrell Healthcare Center's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.