Lakeland Healthcare Center reports medication error, self-reports to state; two low-level citations recommended

Lakeland Healthcare Center officials disclosed to the Board of Trustees on July 16 that an employee gave a resident a PRN (as-needed) medication without a physician’s order, prompting an internal investigation and a self-report to the state Department of Health Services.

The incident was first reported to facility management on June 23, the presenter said; staff who reviewed the case concluded the employee acted willfully. The facility notified the Walworth County Sheriff’s Department, which reviewed the facility’s investigation and observed medication administration; the sheriff’s office also interviewed staff. The presenter said DHS inspected about a week after the facility’s self-report and is recommending two low-level citations: F609 (reporting of abuse) for delayed notification of facility leadership and F760 (medication error) for the improper administration. The facility said it has not yet received a final Statement of Deficiencies.

Why it matters: state regulators treat administration of medication without a physician order as meeting the state definition of abuse when it is willful and could harm a resident. The recommended F-tags carry reputational and regulatory consequences and trigger a required plan-of-correction process.

Board members were told the facility immediately began an internal investigation, reeducated nursing staff on medication procedures and the facility’s abuse policy, and conducted a full audit of PRN medications on the resident’s wing. The presenter said the audit found no other medication mishandling. The facility reported the employee to DHS for further review.

The presenter described a narrow, policy change: if a resident has a PRN medication order but does not use the medication within 30 days, the facility will discontinue that PRN order (the order can be reinstated if the resident needs it and a physician signs a new order). The presenter said that change is intended to reduce the amount of unused PRN medication maintained on the unit.

Regulatory and follow-up steps: the presenter said DHS has 10 business days to send its Statement of Deficiencies and the facility then has 10 calendar days to respond with a plan of correction or request an informal dispute resolution (IDR). The presenter told trustees the facility expects the follow-up to be a desk review and that they will file the required plan of correction promptly.

Discussion vs. action: trustees discussed the incident during the meeting’s “self-report, state survey” agenda item. No formal disciplinary vote or personnel action was recorded in the meeting minutes; the actions described were investigative and administrative (investigation, reporting to DHS, reeducation and policy change). The presenter characterized the employee’s conduct as willful and said DHS was continuing its review.

What remains unspecified: the transcript does not specify the employee’s name, job title, whether the resident experienced harm, nor the exact medication involved; the presenter said the resident was not asking for the medication. The facility said DHS’s recommended citations were “low level” and “no harm” but the facility had not yet received a final written determination.

Next steps for the facility: submit the plan of correction to DHS within the regulatory timeframe, await the agency’s final Statement of Deficiencies, and continue any DHS or law-enforcement follow-up. The facility also said it has reeducated staff and altered PRN policy to reduce future risk.