The woman, identified as Resident #28 in the October 27 inspection report, returned from a hospital stay on October 13 with a doctor's order for pregabalin, a medication used to treat nerve pain and seizures. She didn't receive a single dose until October 20.
Even then, the medication lasted only two days before disappearing again.
"I don't know why my pain medication was stopped," the resident told inspectors on October 27. "The medication was stopped when I returned from the hospital."
The resident suffers from chronic kidney disease, diabetes, anxiety, depression, and lymphedema. Her care plan specifically noted her potential for pain and instructed staff to encourage her to request medication before pain became intense.
After her October hospital admission for dangerously high potassium levels, a physician ordered pregabalin 75 milligrams twice daily for neuropathy. But the medication never arrived.
Progress notes from October 19 revealed the first breakdown in communication. The pharmacy requested a new prescription for the pregabalin, saying they couldn't fill the order without it. Staff contacted an on-call nurse practitioner, who sent a three-day supply prescription to the pharmacy.
That temporary fix worked. The resident received her medication from October 20 through October 22.
Then it stopped again.
A triage note from October 20 revealed another complication. The resident's pregabalin dosage had been changed from 100 milligrams twice daily to 75 milligrams twice daily. The pharmacy said they never received a new prescription reflecting this dosage change.
Staff contacted the nurse practitioner again about the dosage change and the need for a new prescription. But the medication still didn't arrive.
Regional Director of Nursing #300 explained the problem to inspectors. The pharmacy refused to send the pregabalin without a proper prescription. The facility's nurse practitioner insisted the prescription had been sent, but the pharmacy claimed they never received it.
"The on-call doctors and nurse practitioners would only order medications for three days so the facility doctor or nurse practitioner could make the decision whether to continue the medication," the nursing director said.
This policy created a gap. The on-call practitioner provided a three-day bridge supply, but no one followed through with a permanent prescription when that ran out.
The nursing director confirmed the timeline to inspectors. No pregabalin from October 13 at 8:00 PM through October 20 at 8:00 AM. A brief two-day supply from October 20 evening through October 22 morning. Then nothing again from October 22 at 8:00 PM through October 27 at 8:00 AM, when inspectors arrived.
The resident's medical records showed she was cognitively intact and understood her treatment. She knew her pain medication had been ordered but couldn't understand why it kept disappearing.
Progress notes documented each failed attempt to obtain the medication, creating a paper trail of miscommunication between facility staff, on-call practitioners, regular physicians, and the pharmacy.
The facility housed 48 residents at the time of inspection. Federal inspectors reviewed medication administration for three residents and found problems with one.
The pregabalin shortage violated federal requirements that nursing homes provide pharmaceutical services to meet each resident's needs and employ or obtain services of a licensed pharmacist.
Inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. The complaint that triggered the inspection was numbered 2643992.
The resident's care plan emphasized monitoring for changes in usual activities and encouraging early pain management. But for 14 days across a three-week period, she had no access to the nerve pain medication her doctor had prescribed.
While staff documented their attempts to resolve the prescription problems, the resident remained without relief. The medication administration record showed empty spaces where doses should have been given, a stark reminder that administrative failures translate directly into patient suffering.
The inspection found no evidence that alternative pain management was provided during the medication gaps, leaving the resident to manage her neuropathy without the prescribed treatment her physician deemed necessary after her hospital stay.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Signature Healthcare of Galion from 2025-10-27 including all violations, facility responses, and corrective action plans.
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