The medication breakdown at Alamo Nursing Home began when Resident #106 returned to the facility on September 4. Licensed Practical Nurse GG completed the readmission assessment at 2:25 PM and entered medication orders into the computer, but the orders never reached the pharmacy.
Agency Licensed Practical Nurse KK worked the night shift but wasn't told she needed to confirm the medication orders. The resident complained of pain that night, but KK had no medications to give.
"She was not assigned to Resident #106 the day she re-admitted to the facility until 11:00 PM and was not told that she needed to confirm/activate Resident #106's medications," according to the inspection report. "Resident #106 was complaining of pain that night but did not have any medications ordered to administer."
The facility's medication system required a two-step process that staff failed to complete. After one nurse entered orders, another nurse had to perform a "double check" and activate them before they transmitted to the pharmacy.
Director of Nursing B explained that LPN GG had put the medications "into a que" on September 4, but "the second check was not done by the night shift nurse which would have been her expectation."
The pharmacy never received the orders that day. Pharmacy Technician MM confirmed they "did not receive any orders for Resident #106 on 9/4/25 and that the first orders for Resident #106 were received at approximately 6:44 AM on 9/5/25."
Orders placed before 5:00 PM normally arrive by 8:00 PM the same day. The pharmacy delivers medications twice daily at noon and 6:00 PM, with late orders included in the evening shipment.
LPN LL discovered the problem when she arrived for her morning shift on September 5 at 6:00 AM. She found Resident #106's orders still sitting unactivated in the computer queue.
"LPN LL reported she confirmed/activated the orders herself," the report states. "LPN LL reported she then gave Resident #106 the medications she had on hand right away."
But the resident still couldn't get all prescribed medications immediately. Additional medications arrived from the pharmacy that afternoon, though some remained missing even then.
The missed doses included critical medications for pain, seizures, and other conditions. Between 5:30 PM on September 4 and 8:00 AM on September 5, the resident should have received Baclofen for muscle spasms, Gabapentin for nerve pain, and Topiramate for seizure prevention.
The resident also missed Metoclopramide for nausea, Potassium Chloride for heart rhythm, and Buspirone for anxiety. Morning medications that went undelivered included Duloxetine for depression, Montelukast for asthma, and Pantoprazole for stomach acid.
Baclofen was particularly problematic, with the resident missing three separate doses: at 5:30 PM and 11:30 PM on September 4, then again at 5:30 AM on September 5.
The confusion stemmed from a breakdown in the facility's standard admission process. LPN GG said that "typically with an admission, the orders would get entered into the computer as soon as the resident arrived."
But the system's two-step verification process created a gap that left the resident without medication for over 13 hours. The night shift nurse wasn't informed about pending orders, and the day shift nurse had to discover the problem herself.
The Director of Nursing acknowledged the system failure, noting that her expectation was for the night shift nurse to complete the second check and activate the orders.
When orders finally reached the pharmacy at 6:44 AM on September 5, it was nearly 16 hours after the resident's readmission. By then, the patient had endured a night of pain complaints with no available relief.
The incident revealed how communication breakdowns in nursing homes can leave vulnerable residents without essential medications. A simple failure to complete the facility's own verification process resulted in missed doses of drugs for pain, seizures, heart rhythm, and other critical conditions.
Even after staff discovered the problem, some medications remained unavailable as the pharmacy worked to fulfill the delayed orders throughout September 5.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Alamo Nursing Home Inc from 2025-09-22 including all violations, facility responses, and corrective action plans.