F0658

D

Failure to Follow Medication Reconciliation and Administration Standards

Richland, Washington Survey Completed on 01-15-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow professional standards of practice for medication reconciliation, order transcription, and medication administration for a resident admitted with multiple medical conditions, including respiratory failure with hypoxia, hypoparathyroidism, anxiety, and insomnia. On admission, the facility’s policy required a licensed nurse to reconcile home medications with provider orders and hospital documents, obtain clarifications as needed, and accurately enter orders into the electronic medical record with a second nurse verifying accuracy. For this resident, the Skilled Nursing Facility Transfer Orders included an order for levothyroxine 100 mcg with a specific instruction that it must be the brand name Synthroid, and an order for oxycodone-acetaminophen 10-325 mg every four hours as needed for pain. The LPN/Unit Care Coordinator reported verbally reviewing home medications with the resident on the day of admission and stated there were no concerns or changes needed, and also stated they did not see the additional note specifying brand name Synthroid only when entering the orders.

During observation, the resident was found with a clear bag in the bedside table containing a prescription bottle labeled Synthroid 100 mcg and several inhalers, including unopened prescription inhaler boxes. The resident reported keeping their own home Synthroid in the drawer because the generic levothyroxine provided by the facility did not work for them and stated they had informed nursing staff multiple times that they needed the brand name, but staff did not listen. The resident stated that when staff brought levothyroxine to administer, they would throw it on the floor or in the trash and then self-administer their own Synthroid, and that staff left medications in the room without observing administration. A registered nurse confirmed seeing the resident’s Synthroid bottle in the drawer, told the resident they could not take it from them, and instructed the resident to have a loved one take it home, and also stated the order in the system showed levothyroxine, which matched what was in the medication card.

The deficiency also includes failure to ensure timely access to ordered pain medication. The resident stated that on the first day and throughout the first night at the facility, they requested their ordered oxycodone for pain but were told the facility did not have the medication and that obtaining it would be a lengthy process, and that they did not receive any oxycodone until the next day. An LPN stated the resident requested pain medication the morning after admission, but the facility did not have oxycodone available because the pharmacy had not sent it and they did not have an authorization code to obtain it from the pyxis; the LPN also stated they did not call the on-call provider. A registered nurse reported being told that the resident’s medications were not available, acknowledged that oxycodone was in the pyxis but could not be accessed without a pharmacy authorization code, and stated that the appropriate process would have been to call the provider so the provider could contact the pharmacy, but they did not call the on-call provider because calls had already been made. The Director of Nursing Services stated that the process should have included contacting the on-call provider to eScribe a prescription to the pharmacy to obtain an authorization code for the pyxis, and that medications should only be kept at the bedside after an assessment, physician order, and care plan update, which had not occurred in this case.