F0755

E

Failure to Administer Ordered Pain and Antidepressant Medications as Scheduled

Irving, Texas Survey Completed on 01-16-2026

Penalty

No penalty information released

Summary

Surveyors identified a failure by the facility to provide pharmaceutical services that ensured accurate dispensing and administration of medications as ordered for one resident. The resident was an adult female with cirrhosis of the liver, metabolic encephalopathy, chronic hepatitis, depression, and PTSD, with a BIMs score of 8 indicating moderately impaired cognition. Her admission MDS documented use of antidepressant and scheduled pain medications, and her care plan included problems related to liver disease and antidepressant use, with interventions to administer medications as ordered and monitor effectiveness and side effects.

Review of the resident’s January 2026 physician orders showed an order for Hydrocodone-Acetaminophen 7.5-325 mg, one tablet by mouth three times daily for pain starting 01/10/26, and Sertraline 50 mg by mouth at bedtime starting 01/09/26. The DON stated that TID medications were scheduled for 8 AM, 2 PM, and 8 PM, and HS medications at 8 PM. The January 2026 MARs, documented by two medication aides, showed that the resident missed multiple scheduled doses of Hydrocodone-Acetaminophen on 01/12/26 (2 PM, 8 PM), 01/13/26 (8 AM, 2 PM, 8 PM), 01/14/26 (8 AM, 2 PM, 8 PM), and 01/15/26 (8 AM, 2 PM, 8 PM). The MAR also showed missed Sertraline doses on 01/12/26, 01/13/26, 01/14/26, and 01/15/26 at 8 PM.

Despite these missed doses, the MAR documented a pain level of zero from 01/10/26 to 01/16/26, and nursing progress notes from 01/11/26 to 01/16/26 contained no indicators of pain or discomfort. A pain interview on 01/12/26 recorded that the resident experienced pain rarely or not at all. On 01/16/26, the DON reconciled the Hydrocodone-Acetaminophen and Sertraline tablets on the medication cart with the MAR and confirmed that the resident had not received the medications as ordered. Interviews with the resident, the DON, the administrator, both medication aides, and the Activity Director showed that facility staff were unaware that the medications had not been administered, and staff acknowledged that blank MAR entries indicated medications were not given. Facility policies on documentation of medication administration and physician orders required that all medications administered be documented and that physician orders be followed to ensure residents receive necessary care and services.