F0760

D

Failure to Administer and Document Ordered Medications for Two Residents

Wichita, Kansas Survey Completed on 01-21-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, resulting in ordered medications not being administered as prescribed for two residents. One resident with diagnoses including hypothyroidism, myxedema, and prior cerebral infarction had an order for levothyroxine 200 mcg daily starting in early November, later changed to 137.5 mcg daily in January. Review of the Medication Administration Record (MAR) showed multiple dates in November when the 200 mcg levothyroxine dose was not given, with no corresponding order to hold the medication and no documented reason for omission. The resident, who was cognitively intact, reported multiple hospitalizations for hypothyroidism, including a coma prior to admission and an ICU stay with a 10‑day hospitalization in November, and stated that staff had not been giving thyroid medications correctly, sometimes administering them after meals with other medications or not at all.

Staff interviews revealed inconsistent practices and documentation related to medication administration and availability. A Certified Medication Aide (CMA) stated that she did not give the thyroid medication because she believed the night shift nurse had already administered it between 5:00 AM and 6:00 AM, and also described that when medications were not available, staff would look for them and mark them as not given with a specific reason in a note. However, the MAR for the resident with hypothyroidism lacked documentation of reasons for the missed levothyroxine doses. A Licensed Nurse (LN) stated that if a CMA reported a medication could not be found, she would search for it, contact the pharmacy, use the emergency medication kit if needed, and document the reason on the MAR, emphasizing that the MAR should never be left blank and that all medications should be given and documented as ordered.

For the second resident, who had anxiety and bipolar disorder and was cognitively intact, physician orders required alprazolam 0.5 mg every morning and at bedtime for anxiety. The MAR documented nine missed doses over several consecutive days. EMAR administration notes showed repeated notations that the pharmacy was notified, that the medication was not on hand, that the pharmacy reported no prescription on file, and that staff were awaiting a prescription and delivery. On several occasions, the EMAR lacked documentation explaining why alprazolam was not administered. The resident reported that staff missed several doses of his alprazolam. Facility policy on administering medications stated that medications were to be administered in accordance with prescriber orders, in a safe and timely manner, and that administration times should be based on resident need and benefit rather than staff convenience, but the documented omissions and incomplete MAR entries for both residents showed that medications were not consistently administered or documented as ordered.