F0755

E

Failure to Ensure Medications Were Administered and Documented as Ordered

Houston, Texas Survey Completed on 03-17-2026

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 as ordered by physicians for two residents. For one resident with moderately impaired cognition, Type 2 diabetes, hypertension, chronic kidney disease, and insomnia, a physician’s order dated 3/12/2026 directed administration of melatonin 3 mg orally at bedtime, two hours before bedtime, for insomnia. Review of the March 2026 MAR showed blank entries for this melatonin dose on four consecutive days, and review of nursing notes for the same dates revealed no documented reasons for the blanks, despite facility policy requiring documentation of all medication administrations and reasons for any doses withheld, not administered, or refused.

For a second resident, cognitively intact and diagnosed with multiple conditions including hyperlipidemia, dementia, acute chronic diastolic heart failure, hypothyroidism, atrial fibrillation, protein caloric malnutrition, allergy, anxiety, Type 2 diabetes, neuropathy, drug-induced subacute dyskinesia, hypertension, DVT, and insomnia, physician orders were in place for several medications, including aspirin for DVT prophylaxis, Austedo XR for drug-induced subacute dyskinesia, Claritin and fluticasone for allergy-related conditions, and furosemide for heart failure. The survey findings state that the facility failed to ensure this resident received medications as ordered by the physician. The facility’s own medication administration policy, dated April 2007, requires that medication administration be documented immediately after administration and that reasons for any withheld, not administered, or refused medications be recorded, but the report indicates this was not done for the residents reviewed.