F0755

D

Failure to Ensure Ordered Narcotic Pain Medication Was Administered and Properly Documented

Pasadena, Texas Survey Completed on 10-13-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications, specifically Acetaminophen-Codeine 300-30 mg, as ordered for one resident. The resident was an adult female with paraplegia and chronic pain, admitted with a care plan that included anticipating her need for pain relief and responding immediately to any complaint of pain. Her quarterly MDS showed a BIMS score of 10, indicating moderate cognitive impairment. Physician orders dated 2/24/25 directed that she receive Acetaminophen-Codeine 300-30 mg, one tablet by mouth every 8 hours for lower back pain.

Review of the resident’s MARs for multiple months showed repeated use of code 8 (“Other/See Progress Notes”) in place of documented administration of the ordered Acetaminophen-Codeine doses. In May 2025, code 8 was documented for the 8 a.m. and 4 p.m. doses on 5/27/25; in June 2025, code 8 was documented on 6/28/25 at 8 a.m. and on 6/29/25 at 12 a.m., 8 a.m., and 4 p.m.; in August 2025, code 8 was documented on 8/31/25 at 8 a.m.; in September 2025, code 8 was documented on 9/30/25 at midnight; and in October 2025, code 8 was documented on 10/1/25 at midnight, 8 a.m., and 4 p.m. Review of the resident’s progress notes from 9/13/25 to 10/14/25 did not reveal any further documentation explaining the code 8 entries on 9/30/25 and 10/1/25 or confirming that the medication was administered at those times.

In interviews, the resident stated that the facility was supposed to have her medication on time but reported that staff told her the medication was not available and blamed the pharmacy, and that this problem had been occurring monthly since the previous year. She reported that when she did not receive her pain medication, she felt terrible, could not sleep, her tailbone hurt, and she developed a headache. A medication aide reported that she usually administered Tylenol #3 to this resident twice a day, that she had to notify the nurse to reorder narcotics, and that if she documented code 8 on the MAR it meant she likely notified the nurse and did not give the medication because it was not available, possibly due to pharmacy delays; she could not recall the specific reason for the 8/31/25 entry and did not know where the nurse would document if the medication was given from the automated dispensing system. An LVN and the ADON both stated that nurses were responsible for reordering narcotics and denied problems with reordering, though the ADON acknowledged that if a narcotic was not refilled in time there could be unmanaged pain and that the Tylenol #3 was available in the automated dispensing system, but could not explain why the medication was not given. The facility’s policy stated that medications shall be administered as prescribed by the attending physician.