Failure to Administer Thyroid Medication as Ordered
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. The resident, who was admitted with diagnoses including hypothyroidism, did not receive three doses of levothyroxine as ordered. The resident's care plan required daily thyroid replacement therapy, but the Medication Administration Record indicated that only 10 out of 15 doses were administered over a specified period. The Licensed Vocational Nurse (LVN) acknowledged the missed doses and did not complete a change in condition or progress note regarding the missed medication. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were not informed of the missed doses until later, and the facility's policy required notifying the resident's physician and responsible party of any medication errors. The LVN did not inform the DON or initiate a change in condition assessment, which was necessary to monitor the resident for any adverse consequences. The facility's policy on medication errors emphasized the importance of notifying the physician and monitoring the resident according to the physician's instructions.
Plan Of Correction
A total of 19 residents receive Levothyroxine. Nineteen of 19 resident records accurately reflect doses remaining, indicating residents received their medication. C. What measures will be put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: The Director of Staff Development will re-educate licensed nurses on the facility policy and procedure, "Physician Orders," with emphasis on following physician orders including ordered time and frequency of administration on or before 3/21/2025. D. How the facility plans to monitor its performance to make sure solutions are sustained: The Consultant Pharmacist monitors licensed nurses' proper administration of medication during routine facility audits and reports the findings to the QAA Committee, at a minimum quarterly, for the purpose of process improvement. The Director of Nursing will monitor the Director of Medical Record audits of resident medication, Levothyroxine, to ensure residents receive their medication in accordance with physician orders. The Director of Medical Records/designee will audit the administration times of residents with Levothyroxine orders to ensure residents receive medication during an acceptable timeframe for medication administration, monthly. Results of the medication administration audit will be given to the Director of Nursing for further review, analysis, and follow-up as indicated. Compliance concerns identified will be corrected immediately and reported to the Director of Nursing for further corrective action as indicated. If the DON identifies residents who did not receive their Levothyroxine in accordance with physician orders, the DON will begin an investigation into the medication error as applicable and identify the root cause of the variance to the physician order to re-educate or discipline as determined. The facility plans to monitor its performance to ensure solutions are sustained through ongoing oversight and reporting. Trends identified in the administration of Levothyroxine and other medications will be reported by the Director of Staff Development to the Quality Assurance committee during the quarterly QA&A meeting for the purpose of process improvement changes to ensure continued compliance with this plan of correction. Allegation of Compliance Date: 3/25/2025 F689 Free of Accident Hazards Supervision/Devices CFR(s): 483.25(d)(1)(2) A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: 1. The licensed nurse removed two tubes of triamcinolone acetonide from Resident 41's bedside table on 2/24/2025. 2. Resident 348's floor pad alarm was activated by a certified nurse assistant on 2/28/2025. 3. Housekeeping cleaned the spill and placed a wet floor sign in the area of nine residents when fluids were identified on the floor on 2/25/2025, to reduce the potential to result in falls resulting in injuries like fractures. 4. Furniture in the rooms of Residents 34, 83, and 42 were removed from the floor pad mat to reduce the risk of injury from a fall on 2/28/2025. 5. The IDT completed a fall assessment for Resident 83 and reviewed and revised the 2/24/25 care plan for injuries related to falling.