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F0755
E

Delayed Medication Administration for Two Residents

Grapevine, Texas Survey Completed on 04-15-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide pharmaceutical services that ensured the timely and accurate administration of medications for two residents. Specifically, a medication aide (MA) administered Gabapentin, ordered for pain management, to one resident and Creon, ordered for exocrine pancreatic insufficiency, to another resident more than one hour after the scheduled administration time. Both residents were scheduled to receive their 8:00 am medications, but did not receive them until after 9:30 am. The medication administration records (MAR) for both residents were not initialed as given at the scheduled time, and interviews confirmed the delay. One resident, a cognitively intact male with diagnoses including muscle disorders, cellulitis, chronic foot ulcer, and neuropathy, reported not receiving his pain medication on time and expressed discomfort and pain during the interview. His care plan required medication to be administered as ordered for pain management. The other resident, also cognitively intact and diagnosed with bullous pemphigoid, exocrine pancreatic insufficiency, and other pancreatic diseases, did not receive his Creon medication with his meal as ordered, which was confirmed by both the resident and the MAR review. His care plan specified that medications should be administered with meals. The MA responsible for administering these medications was delayed in starting the medication pass due to participation in a medication pass observation with a nurse surveyor earlier that morning. This delay resulted in the late administration of scheduled medications for both residents. Facility policy required medications to be administered within one hour of the prescribed time unless otherwise specified, which was not followed in these instances.

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