F0755

E

Failure to Administer Psychotropic and Antiseizure Medications Within Prescribed Time Frames

Waco, Texas Survey Completed on 02-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide pharmaceutical services that ensured timely administration of medications as prescribed for three residents. For one male resident with schizophrenia, acute kidney failure, moderate intellectual disabilities, and severe cognitive impairment (BIMS score of 1), the care plan included monitoring for medication side effects and providing medications as ordered. His active order for Risperidone 1 mg twice daily for schizophrenia was not administered within the facility’s required one-hour window on three consecutive mornings, with doses scheduled for 9:00 a.m. instead given at 10:20 a.m., 11:36 a.m., and 10:16 a.m. respectively.

A female resident with muscle weakness, schizophrenia, major depression, and moderate cognitive impairment (BIMS score of 10) also had an active order for Risperidone 0.5 mg twice daily for schizophrenia and a care plan that included observing for side effects and providing medications as ordered. The medication administration audit report for this resident, filtered for administrations more than one hour late, showed that her antipsychotic medication was not consistently given within the prescribed time frame, although the specific late times are partially truncated in the report. Another resident with a history of seizures and depression had active orders for Valproic Acid 15 ml twice daily and Venlafaxine 75 mg once daily, and the audit report showed these medications were administered outside the standard time frame over several days.

Interviews and policy review further described the circumstances leading to the deficiency. A medication aide stated that medication aides were responsible for ensuring residents received medications on time, which she defined as within a two-hour window, and that if medications were going to be late, she would notify the nurse, who would then notify the physician. The DON stated that all nurses and medication aides were responsible for timely medication administration, that administration did not run late medication reports daily and therefore had not monitored late medications, and that medications should be given within one hour before or after the designated time on the order. The facility’s written policy on administering medications required that medications be administered in a safe and timely manner, within one hour of their prescribed time unless otherwise specified.