Failure to Administer Medication as Ordered and Document Omissions
Penalty
Summary
The facility failed to ensure that medications were administered as ordered for one resident who was prescribed Synthroid (levothyroxine) 25 micrograms in the morning for hypothyroidism. Review of the medication administration records for March, April, and May revealed multiple dates with blanks for levothyroxine, indicating missed doses. The facility's policy required that all physician orders be followed as prescribed and that any deviations be documented in the resident's medical record during the shift. However, both the CMA and the DON confirmed that blanks on the medication administration record meant the medication was not administered, and there was no documentation explaining why the doses were missed. The pharmacy had previously identified these omissions and confirmed with the physician that the administration time should not be changed, but the issue persisted without proper documentation or explanation.