Failure to Administer Prescribed Medication and Notify Physician
Penalty
Summary
A deficiency occurred when a resident with diagnoses including acute and chronic respiratory failure, congestive heart failure, and hypothyroidism did not receive their prescribed Liothyronine medication as ordered by the physician. The physician's order specified administration of Liothyronine 25 mcg orally four times daily, but the medication was not given at several scheduled times. Documentation in the Medication Administration Record (MAR) indicated missed doses with comments such as 'awaiting pharmacy delivery,' and in some instances, there was no comment or rationale provided for the omission. Interviews with facility staff revealed that the process for obtaining and administering medications involved the Unit Manager entering orders, pharmacy verification, and delivery to the facility. If a medication was unavailable, staff were expected to notify the physician and seek alternatives. However, in this case, there was no documentation that the physician was informed about the missed doses, and the required follow-up actions were not completed. The Director of Nursing confirmed that staff should have documented a rationale for any missed medication and notified the physician and Unit Manager. Facility policy required immediate notification of the nursing supervisor and physician if a medication was unavailable, contacting the pharmacy, and documenting the reason for any missed dose in the EMAR. These procedures were not followed, resulting in the resident not receiving their thyroid medication as ordered and the lack of appropriate documentation and communication regarding the omissions.