F0755

D

Failure to Obtain and Administer Ordered Opioid Analgesic for New Admission

Longview, Texas Survey Completed on 02-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure ordered pain medication was accurately acquired, received, and available for administration to a resident following admission. The resident, an elderly female with a nondisplaced intertrochanteric fracture of the left femur, bipolar disorder, and anxiety disorder, was admitted without her medications from the hospital. An order dated 1/19/26 for Hydrocodone-Acetaminophen 5-325 mg to be given by mouth as needed for moderate to severe pain was in place, but review of the medication administration record for January 2026 showed that this medication was never administered at any time during her stay.

Staff interviews and record review showed multiple points of failure in obtaining the ordered Hydrocodone-Acetaminophen. The NP stated she attempted to pull the medication from the Pyxis system on the night of admission but was denied because the prescription was not signed by the physician, and the resident instead received over-the-counter pain medications. LVN B confirmed that the resident arrived without medications, that an attempt to obtain Hydrocodone-Acetaminophen from Pyxis was denied due to the lack of the medical director’s signature, and that the family was notified and declined transfer to the emergency room for pain management. LVN B reported sending a message to the NP about the medication issue on 1/19/26 but stated the NP did not respond until early the next morning.

Further interviews revealed uncertainty and breakdowns in communication and pharmacy processing. The NP later learned on 1/21/26 that the Hydrocodone-Acetaminophen prescription had not reached the facility and then called in an order for Acetaminophen-Codeine 300-30 mg, which was subsequently administered multiple times as documented on the MAR. The ADON suspected a pharmacy error related to a recent pharmacy change and possible incorrect physician contact information. The Administrator stated he expected nurses to obtain pain medications quickly and that the nurse should have contacted the DON or Administrator so the medical director could provide a valid prescription. The DON stated that nursing management was responsible for ensuring ordered medications were procured and available and that residents could be placed at risk of uncontrolled pain if prescribed pain medications were not available. The facility’s medication administration policy required medications to be administered safely, timely, and as prescribed, under the supervision of the DON.