Failure to Document Administration of Thyroid Medications
Penalty
Summary
The facility failed to follow pharmacy documentation procedures for the administration of thyroid medications for two residents. For one resident, review of physician orders and medication administration records (MARs) over a three-month period showed multiple instances where Levothyroxine was not signed off as administered on specific dates. The resident's medical record indicated persistently high thyroid stimulating hormone (TSH) levels, and the resident reported not taking her medication as prescribed. The physician assistant's notes also reflected concerns that the resident had not been receiving her Levothyroxine as ordered while at the facility, leading to dose adjustments. For another resident, the MARs revealed several dates in February and March where Levothyroxine administration was not documented. An interview with the Director of Nursing confirmed that medication administration should be documented at the time of administration, and acknowledged awareness of the documentation lapses. Facility policy requires immediate documentation of all administered medications, but this procedure was not consistently followed for these residents.