Failure to Administer Prescribed Medications Upon Admission
Penalty
Summary
A deficiency occurred when a resident was admitted to the facility with physician's orders for Synthroid (levothyroxine) and Ajovy (fremanezumab-vfrm) as documented in the acute care hospital's discharge report. During the admission process, these medication orders were omitted from the facility's electronic health record. The resident, who was cognitively intact and able to communicate medical needs, did not receive Synthroid for ten days after admission, and there was no evidence that Ajovy was administered. The omission was not identified or clarified with the physician, the resident, or family members during the initial medication reconciliation. Interviews with nursing staff revealed that the nurse responsible for entering the orders missed the Synthroid and did not enter Ajovy due to a lack of frequency information on the discharge report. There was no double-checking of the medication list to ensure all orders were transcribed, and no follow-up occurred to clarify missing information. The resident reported feeling weak several days after admission, but this was not associated with the missed medication by staff, and no monitoring or laboratory tests were initiated in response to the resident's symptoms.