F0755

D

Medication Administration and Discontinued Drug Storage Failures

Terrell, Texas Survey Completed on 03-05-2026

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 for multiple residents. For a male resident with chronic systolic congestive heart failure and generalized anxiety disorder, the physician had ordered buspirone 5 mg to be given three times daily starting in mid-January 2025. His MDS showed intact cognition (BIMS 15) and documented use of antianxiety and antidepressant medications, and his care plan directed that buspirone be administered as ordered. The MAR from October 2025 through March 2026 showed the buspirone as administered three times daily, except for one documented absence from the facility. However, during a medication pass observation, the buspirone card in use had 42 tablets remaining from a card dispensed in late November 2025, and the medication aide stated there was no overstock for this resident on the cart or in storage.

On the following day, surveyors observed that the same medication aide’s cart actually contained three additional overstock cards of buspirone 5 mg for this resident, dispensed in July 2025, October 2025, and January 2026, with substantial tablet counts remaining. In an interview, the resident reported that he sometimes received his midday dose of buspirone and sometimes did not, and that he had reported this to the DON, although he could not recall when. He stated that when he remembered, he would go ask for the medication and that the medication aide in question was the only one not administering his buspirone. The DON acknowledged that the resident had reported not receiving his noon dose from this aide, that she had questioned the aide and reviewed the medication cards, and that she had provided verbal education, but there was no documentation of this.

A second deficiency involved a female resident with chronic respiratory failure with hypoxia, bipolar disorder, and depression, whose MDS also showed intact cognition (BIMS 15) and receipt of antidepressant medications. Her care plan addressed depression with administration of medications as ordered. Physician orders showed an active order for sertraline 50 mg once daily and a discontinued order for sertraline 100 mg in the morning, which had been stopped in late January 2026. Despite this discontinuation, surveyors observed both sertraline 100 mg and 50 mg on the medication cart. The medication aide stated she did not know why the discontinued 100 mg dose remained on the cart and acknowledged that discontinued medications should be removed. The DON reported that she relied on weekly cart checks and had not noticed the discontinued sertraline remaining on the cart, while an LVN and another medication aide gave conflicting accounts about whether the discontinuation had been communicated, demonstrating a breakdown in the process for removing discontinued medications from active stock.