F0755

E

Failure to Ensure Accurate Medication Administration and Observation of Ingestion

Garland, Texas Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate dispensing and administration of medications, including failure to follow prescriber orders and to observe residents ingest their medications. One cognitively intact female resident with extensive cardiac, hepatic, hematologic, and psychiatric diagnoses, including a prosthetic heart valve and a care plan identifying risk for bleeding, was ordered Warfarin Sodium 4 mg, two tablets by mouth at bedtime for clotting related to heart failure. Interview and record review showed that on two evenings she was provided a total of four Warfarin tablets instead of the ordered two, after being approached by staff on two separate occasions during the same evening medication pass. The resident reported receiving two Warfarin pills from a certified medication aide (CMA) around one hour after already receiving two Warfarin pills earlier that evening, and on the second night she again received an additional two Warfarin pills after having already taken her ordered dose.

The resident stated that on the second night she informed the staff member that she had already received her medications and was not supposed to receive another dose, but the staff member told her they knew what she was supposed to receive and proceeded to give the medication, then walked away without observing ingestion. The resident hid the additional Warfarin tablets under her blanket instead of taking them and later showed them to her roommate, who confirmed that the CMA did not observe either resident swallow their medications. The next morning, the resident gave the two Warfarin tablets to a different CMA, explaining they were extra pills she had not taken. That CMA reported receiving the pills and the explanation from the resident, then passed the pills to the floor RN. The RN acknowledged receiving the returned Warfarin tablets, being informed they were not taken the previous night, and then handing them off to an LVN at shift change without documenting the event, discarding the medication, or following up.

Additional interviews revealed a pattern of staff not consistently observing residents take their medications, particularly bedtime medications for sleep. The roommate of the first resident, who was cognitively intact and required staff assistance with several ADLs, reported that she was given Melatonin 3 mg at bedtime but that the CMA did not watch her take it; she held onto the pill until she was ready to sleep and stated that staff did not always observe her or her roommate taking medications. A cognitively intact male resident with insomnia and multiple comorbidities, including COPD and CNS disorder, reported that staff did not always observe him take his Zolpidem Tartrate 5 mg; he stated that staff often gave his sleep medication early in the evening and he would hold onto it until he was ready for sleep, sometimes calling staff over later to show he had taken it. The DON and Administrator stated they were not aware of the Warfarin medication errors and confirmed that the expectation and facility policy were that nurses and CMAs must monitor residents while taking medications, never walk away without observing ingestion, and that any medication returned by a resident should be discarded, documented, and reported. Facility policies on administering medications and on adverse consequences and medication errors required medications to be administered as prescribed, inappropriate or excessive doses to be addressed with the prescriber, and medication errors to be documented and monitored, which did not occur in these instances.

Further interviews with staff involved in the Warfarin administration showed additional failures in medication control and documentation. The CMA who worked weekend double shifts acknowledged administering Warfarin to the resident twice in the evening on at least one day, totaling four pills, stating she gave what appeared in the electronic system and that both med aides and nurses were responsible for administering blood thinners. She stated she believed she observed the resident take the medications and was unaware the resident had not taken the extra pills. The LVN who received the returned Warfarin from the RN identified the pills as Warfarin, determined they could only belong to the resident on Warfarin, and learned from the resident that she had received an additional dose after already taking two pills. The LVN reported finding two packs of Warfarin on the med aide cart in addition to packs on the nurse’s cart, removed the extra packs from the med aide cart, and discarded the returned pills without documenting the incident or reporting it to the DON. These actions and inactions, including duplicate Warfarin availability on multiple carts, failure to follow physician orders, failure to observe medication ingestion, and failure to document and report medication errors, led to the cited deficiency in pharmaceutical services.