Failure to Implement Pharmacy Recommendations for Medication Administration Times
Penalty
Summary
The facility failed to ensure that pharmacy recommendations regarding medication administration times were implemented as agreed upon by the physician for a resident with hypothyroidism. The resident was prescribed Levothyroxine Sodium, Ferrous Sulfate, and Magnesium Oxide, and the contracted pharmacist made two separate recommendations to adjust the administration times to prevent potential binding and ensure proper absorption of Levothyroxine. Both the nurse practitioner and physician agreed to these recommendations, which specified that Levothyroxine should be administered first thing in the morning, at least 30 minutes before other medications, and separated by at least four hours from iron and magnesium-containing products. Despite these recommendations and physician agreements, review of the resident's electronic medication administration records (eMAR) for several months showed that Levothyroxine, Ferrous Sulfate, and Magnesium Oxide were frequently administered within four hours of each other, and sometimes at the same time. Out of 30 documented administrations, only two instances met the recommended separation interval, while the majority did not. There was also an instance where Levothyroxine was administered in the evening rather than in the morning as recommended. The facility's Regional Director of Quality Assurance confirmed these findings and was unable to explain why the administration times were not adjusted according to the recommendations and physician orders. The facility's policy required monthly medication regimen reviews by a consultant pharmacist and communication of findings to the prescriber and director of nursing. However, the policy did not address the need for facility staff to implement recommendations that had been agreed to by the physician. This gap contributed to the ongoing failure to adjust medication administration times as recommended and ordered, resulting in the identified deficiency.