Failure to Timely Re-Order and Securely Administer Medication
Penalty
Summary
Facility staff failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of medications for a resident. Specifically, staff did not re-order levothyroxine 50 mcg in a timely manner, resulting in a missed dose for a male resident with diagnoses including malnutrition and seizure disorder. The medication administration record indicated a missed dose, and there was no documentation in the progress notes to explain the omission. During medication administration, the nurse was unable to locate the medication and did not retrieve it from the E-Kit as required. Instead, the nurse borrowed levothyroxine from another resident's supply and administered it, which was confirmed during a subsequent interview. The nurse admitted to not following the proper procedure due to being in a hurry and not knowing why the medication had not been re-ordered. Other staff interviews confirmed that nurses are responsible for re-ordering medications when a 7-day supply remains and that the E-Kit is available for such situations. The facility's policy requires timely re-ordering and use of electronic systems to track medication needs.