F0755

E

Medication Control, Documentation, and Packaging Failures in Pharmacy Services

Galveston, Texas Survey Completed on 03-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, administering, and accounting of medications for multiple residents. For one resident with convulsions, hypertension, and traumatic brain injury, the control count sheet for Lacosamide oral solution (10 mg/mL, 20 mL via G-tube twice daily) documented 480 mL, while two bottles on the medication cart contained a total of 510 mL (one unopened 400 mL bottle and one 110 mL bottle). The RN conducting the count identified the discrepancy but stated she did not know what to do, suggested it might be a documentation or measurement error, and reported she had not received any skill check-off on medication administration or controlled drug counts since starting work three weeks earlier. The resident’s quarterly MDS showed severely impaired cognition and extensive to total assistance needs, and the resident had no current care plan after the prior plan was canceled.

For a second resident with dementia, hypertension, and diabetes mellitus, who had a care plan identifying risk for pain and an order for tramadol 50 mg by mouth every six hours as needed for pain, surveyors observed that one tramadol blister pack on the medication cart had a punched-open seal with the tablet half exposed. The RN present stated she did not know what to do about the partially opened blister and reported she had not received training on medication administration or controlled drug counts. The DON later stated that if a tramadol blister pack seal was broken, the medication should be wasted with another nurse and documented on the control sheet, and also stated they were not sure if the medication in the opened blister was the original medication and that if not destroyed, the medication could come up missing and would be reportable for drug diversion.

For a third resident with obesity, hypertension, and diabetes mellitus, who had intact cognition and a care plan for pain management with analgesic medications, the order summary showed acetaminophen-codeine 300-30 mg, one tablet by mouth every four hours as needed for pain. The control count sheet for this controlled medication showed 16 tablets, but the blister pack contained only 15 tablets. The LVN stated she had administered one tablet at 1:30 p.m. and forgot to sign it out on the control sheet or the MAR, and when asked when she should sign the control book and MAR, she shrugged her shoulders and reported she had not had any training on medication administration since starting at the facility, aside from three days of floor orientation. The facility’s written policy required the individual administering medication to initial the MAR after giving each medication and before administering the next one, and the surveyor’s request for a drug diversion policy was not fulfilled. The DON acknowledged that if controlled medications are not signed out when pulled, it would look like drug diversion and stated she had not had time for comprehensive nursing training while covering multiple roles.