Failure to Monitor and Appropriately Indicate Medications in Drug Regimens
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary drugs and that appropriate monitoring was conducted for certain medications. For two residents receiving high-dose Vitamin D supplementation, there was no documentation of baseline or ongoing laboratory monitoring to assess Vitamin D levels. Both the LVNs and the DON acknowledged that Vitamin D was being administered without lab orders or monitoring, and the pharmacy consultant confirmed the importance of obtaining baseline labs and periodic monitoring to determine the necessity and safety of continued supplementation. One resident was administered Torsemide for edema and Sevelamer HCl for hypocalcemia, but the resident did not have a diagnosis of edema or hypocalcemia. The order for Sevelamer HCl was written for hypocalcemia, but the medication is indicated for high phosphate levels, and the resident's calcium levels were within normal range while phosphate levels were elevated. The DON and pharmacy consultant both acknowledged that the indications for these medications were incorrect and that clarification with the physician was necessary before administration. Additionally, two residents were administered amiodarone without appropriate monitoring of thyroid-stimulating hormone (TSH) levels, despite the known risk of thyroid dysfunction associated with this medication. In one case, a resident had a critical TSH lab value and a nurse practitioner's order to adjust levothyroxine dosage and recheck TSH in six weeks, but there was no documentation that these orders were implemented. In another case, a resident had a TSH level of 0.00, a critical value, with no follow-up or new lab orders completed. The DON and pharmacy consultant confirmed that these lapses in monitoring and follow-up did not meet expectations for safe medication management.