F0759

E

Medication Pass Error Rate Exceeds 5% Due to Late Administration

San Antonio, Texas Survey Completed on 03-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain a medication error rate below 5%, as surveyors identified a 16.12% error rate during a medication pass. During observation of a medication administration by one LPN, five of thirty-one medication opportunities were administered late to one resident. Specifically, the LPN administered Docusate Sodium, Fluoxetine HCl, Meloxicam, Methenamine Hippurate, and Polyethylene Glycol at 12:12 p.m., which was one hour and twelve minutes after the end of the scheduled administration window of 7:00 a.m. to 11:00 a.m. This late administration was identified through observation, interview, and record review.

The resident involved was an elderly female with diagnoses including a left wrist carpal fracture, constipation, depression, and urinary tract infection. Her 5-Day MDS showed a BIMS score of 11, indicating moderate cognitive status, and documented frequent pain rated 5 out of 10, need for substantial/maximal assistance with mobility and transfers, and active UTI, fracture, and depression. Her care plan included interventions to administer medications as ordered for constipation, UTI prophylaxis with Methenamine Hippurate, pain management with analgesics, and depression treatment with Fluoxetine. The active medication orders confirmed scheduled dosing for the medications that were administered late, including bowel maintenance, antidepressant therapy, pain control after breakfast, and chronic UTI management.