San Antonio Home Health

“Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on observation, clinical record review and interview, the agency failed to ensure accurate medication review and reconciliation for the pain medication Gabapentin 100 Mg Capsule for one of seven patients (Patient #4) whose records were reviewed. This failure, by the agency, placed patient and other potential patients at risk for medication errors, adverse drug occurrences and potential harm. During observation visit for Patient #4 on 09/10/2025 at 11:00 am, a medication discrepancy was found while the agency Registered Nurse (employee D) was conducting medication regimen/assessment. One medication, a bottle of Gabapentin 100 MG with the directions of take one capsule by mouth twice daily in Patient #4s basket at the bedside was not included in current medication administration record the registered nurse was reviewing. During observation visit for client #4 on 09/10/2025 it was observed from the Registered Nurse’s employee D patient assessment that patient #4 was alert and oriented to who she was, where she was, and what time it was. Patient #4 was readily able to understand and answer questions from the RN D. Record review of Patient #4s orders showed admission into hospital on 08/19/2025, discharge from same hospital on 08/25/2025 and ROC (Resumption of Care order dated 08/25/2025). Record review of Patient #4s ROC showed RN F. conducted and documented ROC on 08/26/2025 and the missing medication Gabapentin 100 Mg from current MAR on observation visit 09/10/2025, had been discontinued on 08/25/2025. The ROC documentation dated 08/26 2025 did not reveal any documentation that Patient #4 was aware of the Gabapentin discontinuance and or to stop taking the Gabapentin Record review of nursing visit conducted by agency LVN Licensed Vocational Nurse E dated 08/29/2025 revealed no documentation of a medication regimen review or assessment conducted. Record review of agency policy and procedure titled Medication Management PC.75-page 2 Policy undated read in part, “The agency will ensure that assessments both prescription, non-prescription, and as needed (PRN) that the patient/client is taking and document in the clinical record”. Procedure PC.75 page 3 undated read in part, “Medication assessments are continuous and ongoing occur at every scheduled clinical visit and are documented in the clinical record. During the observation visit on 09/10/2025 at 11:00 am, an interview was conducted with patient #4. This surveyor asked Patient #4 how long she had been taking the Gabapentin? Patient #4 answered, “I have been taking the medication since the first of the year but this new dosage since before I went to the hospital”. Patient#4 was asked, did you continue to take medication after coming back from hospital? Patient #4 said “yes”. Patient #4 was asked, when do you take the medication? Patient #4 answered, “I take one capsule in the morning and one at night everyday”. Patient #4 was asked, why do you take the medication? Patient #4 answered, “for pain”. Patient #4 was asked, has any nurse from the agency told you the medication was discontinued? Patient #4 answered, “I do not believe so”. In a continued observation visit and interview on 09/10/2025 at 11:50 a.m. with Patient #4 and with RN D. RN D. was asked if she was the patient’s regular nurse? RN answered, “I am not, this is my first visit with this patient”. RN D was asked, what are your next steps concerning the medication discrepancy? RN answered, “I am going to call the doctor to see if he wants to continue medication and call the agency to make them aware of situation”. During an interview with Administrator on 09/15/2025 at 2:15 pm, the Administrator was given the opportunity to review the above findings. The Administrator acknowledged the agency failed to conduct and/or document medication assessment and medication regimen review with Patient #4 per agency policy and due to the absence of documentation. The Administrator was asked who was responsible for this process? The Administrator answered,” it is the responsibility of the agency to enforce the policy and make sure agency staff were following and documenting. The Administrator was asked how can this affect patient care? The Administrator answered, “Taking medication not prescribed by and without the doctors oversite could put patient at risk”.”