Failure to Obtain Ordered TSH Monitoring for Resident on Amiodarone
Penalty
Summary
A deficiency occurred when a resident receiving amiodarone 200 mg daily for paroxysmal atrial fibrillation did not have appropriate thyroid monitoring as recommended. The Consultant Pharmacist reviewed the resident’s medications upon admission and identified that there was no TSH (thyroid stimulating hormone) level documented in the medical record for the previous six months, despite the resident’s ongoing amiodarone therapy. The pharmacist documented a recommendation on 10/27/25 for a TSH level to be obtained on the next convenient lab day and every six months thereafter. A physician order for a one-time TSH blood test was entered on 11/06/25, but the test was never drawn, and the order automatically discontinued within 24 hours. The DON stated that the TSH lab was not obtained as ordered, that the order was entered as a one-time order which auto-discontinued, and that she did not follow up to confirm that the TSH was drawn or re-order it when it was missed. Review of the resident’s electronic and paper records showed no TSH results from this order and no prior TSH results from the hospital discharge record. The physician later confirmed being notified that the TSH order had not been completed and stated he was not concerned because the test was for monitoring purposes.
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