F0755

E

Prefilling of Routine and Controlled Medications in Violation of Medication Administration Policy

Sherman, Texas Survey Completed on 02-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide pharmaceutical services and to follow its own medication administration policy, including procedures to assure accurate administration of drugs and biologicals, for six residents observed during a medication pass. Medication Aide (MA) A was observed using prefilled medication cups stored in the top drawer of the medication cart, each labeled with a resident’s name and containing multiple pills that had been pulled before the scheduled administration time. For one resident, MA A retrieved a plastic cup already filled with several pills, then had to go to another medication cart to obtain the resident’s blister packs and compare the contents of the cup with the electronic medication administration record (eMAR) and the blister packs before administering the medications.

In another instance, MA A was observed transporting two medication carts to a different hall to administer a second resident’s medications. The top drawer of one cart contained multiple prefilled medication cups labeled with different residents’ names. MA A selected the cup labeled for the second resident, then compared the pills in the cup with the blister packs and the eMAR and discovered that a cranberry tablet had been omitted. She then opened the cart, retrieved a cranberry tablet from a bottle, and added it to the prefilled cup containing other previously pulled medications such as amiodarone, Plavix, Eliquis, potassium chloride, vitamin C, and a multivitamin before administering them. Later, MA A pulled another prefilled cup labeled for a third resident whose medications were scheduled for 7 a.m. but had been delayed at the resident’s request. She compared the contents with the blister packs and eMAR, which showed that the cup already contained multiple medications, including controlled substances (Ativan and hydrocodone/acetaminophen), as well as other drugs such as carbidopa-levodopa, Wellbutrin XL, Lasix, primidone, and Flomax, and then administered them.

During interview, MA A acknowledged knowing that she was not supposed to prefill medications and that she was required to follow the rights of medication administration (right resident, right medication, right dosage, right time, and right route). She stated she had been having difficulty completing medication passes within prescribed times because residents’ routine medications were scheduled at different times and she had to move between multiple carts and halls, so she took a shortcut by prefilling medications and consolidating them into one cart. She also stated she had requested that nurses correct administration times but that this had not been done due to staff changes, and she recognized that prefilling medications posed risks such as medications being spilled or the wrong resident’s medications being given.

A separate deficiency was identified with MA B, who was observed at another medication cart with three prefilled medication cups in the top drawer, each labeled with a different resident’s name and containing controlled medications scheduled to be given with morning medications. MA B unlocked the narcotic lock box, pulled the blister packs, and compared them with the eMAR and the pills in the cups, confirming that the cups contained tramadol for two residents and hydrocodone/acetaminophen for a third resident. MA B stated she had pulled all of the narcotics at once around 8:45 a.m. for a 9:00 a.m. medication pass to save time, despite knowing that she was supposed to pull and sign out controlled medications one resident at a time at the time of administration. She acknowledged that prefilling and leaving medications in the cart could result in medications being mixed up, spilled, or given to the wrong resident.

The Assistant Director of Nursing (ADON) stated that staff were not allowed to prefill medications for multiple residents and were required to prepare medications at the time of administration. The ADON explained that prefilling and storing multiple residents’ medications in the cart created the possibility that medications could be spilled, mixed up, or taken for the wrong resident, and that narcotics and controlled medications were to be signed out and administered at the same time. The Director of Nursing (DON) confirmed that prefilling medications was not consistent with facility policy, which required staff to compare medications with the eMAR at the time of administration to ensure the right dose, medication, resident, route, and time, and noted that some medications required parameters to be checked prior to administration that could be overlooked if medications were prefilled. The facility’s written policy on administering medications specified that medications are to be administered in a safe and timely manner as prescribed, that the individual administering medications must verify resident identity, and that the medication label must be checked three times to verify the right resident, medication, dosage, time, and route before administration.