F0755

J

Failure to Obtain and Administer Ordered Anticonvulsant and Pain Medications

Texarkana, Texas Survey Completed on 03-06-2026

Penalty

Fine: $127,250

Summary

The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications for residents, specifically seizure and pain medications. One cognitively intact male resident with epilepsy had an active order for Topamax 25 mg PO three times daily for seizure prevention. His February MAR showed multiple doses not administered beginning on 02/10/2026, with entries marked as “other/see progress note,” and documentation that the medication was not available. The resident’s care plan required seizure medications to be given as ordered and for staff to monitor effectiveness and side effects, but the ordered Topamax was not on hand from 02/10/2026–02/15/2026, and the facility did not obtain the drug from the pharmacy, pyxis, or a local pharmacy during that period.

Staff interviews revealed inconsistent and incomplete follow‑up on the missing Topamax. Medication aides reported notifying charge nurses and the ADON that the resident was out of Topamax and that the medication had not arrived after being ordered, but some nurses did not follow through with the pharmacy. The ADON stated she had called and faxed the pharmacy multiple times and believed the Nurse Practitioner had been informed that the resident had missed multiple doses, but she acknowledged she did not document any of these contacts or the missed doses. The Nurse Practitioner, however, stated she had no knowledge that the resident was without Topamax prior to 02/15/2026 and only learned on that date that the resident had missed five days of doses. The physician also reported he was not notified that the resident had missed Topamax doses, had seizure‑like episodes, or had been transported to the hospital, and pharmacy records showed no refill activity between 01/26/2026 and 02/15/2026 despite the facility’s claims of repeated contacts.

A second cognitively intact male resident with chronic pain and an order for scheduled hydrocodone‑acetaminophen 10‑325 mg PO three times daily also experienced prolonged unavailability of his medication. His MAR and administration notes from late January through early February documented repeated missed doses with notations such as “waiting on arrival,” “on order,” and “N/A,” indicating the drug was not in the building. Progress notes for this period did not show that the physician, NP, or pharmacy were notified that the resident was out of hydrocodone. A triplicate request form for the hydrocodone dated 01/05/2026 contained an undated, unsigned handwritten note stating a new triplicate was required because the pharmacy had changed, but there was no evidence of follow‑up to secure the medication. The resident reported he went without his pain medication for about five days, experienced excruciating back and neck pain with numbness in his hands and fingers, could not sleep, and became agitated and irritable, while staff only offered non‑pharmacologic measures such as repositioning and pillow adjustment.

Across both cases, staff accounts showed confusion and disagreement about responsibilities for ordering, tracking, and following up on medications. Medication aides stated they were not allowed to call the pharmacy and relied on nurses, while at least one LVN stated MAs had the same access she did and should handle their own follow‑up. The ADON reported there was no clear system in place for ordering and receiving medications after a corporate pharmacy change, and that staff often did not know which pharmacy number to call. The Corporate Regional Nurse acknowledged that the facility had experienced problems after the corporate pharmacy change and that an acute review later identified missed medications due to unavailability, but maintained that the facility had notified the NP and followed up with the pharmacy. The survey identified that the facility failed to ensure timely acquisition and administration of ordered medications, failed to consistently notify the physician/NP when medications were unavailable, and failed to document and escalate these issues, resulting in missed anticonvulsant and pain medications for two residents.