Improper Administration of Time-Sensitive and Delayed-Release Medications
Penalty
Summary
The facility failed to ensure medications were administered according to physician orders and manufacturer recommendations, resulting in a medication error rate of 7.69% (2 errors out of 26 opportunities) during a medication pass observation. A 92-year-old resident with dementia, dysphagia, hypertension, tachycardia, and hypothyroidism had physician orders for Levothyroxine Sodium 50 mcg to be given once daily as a time-sensitive medication at 6 AM (earliest 5 AM) and Aspirin 81 mg delayed-release once daily for VTE. On December 29, 2025, at 10:23 AM, a nurse administered multiple medications to this resident, including Levothyroxine and Aspirin, after the resident had already eaten breakfast, and crushed both medications, which converted the Aspirin delayed-release tablet into an immediate-release dose. The manufacturer’s recommendation for Levothyroxine specified administration on an empty stomach, 30 minutes to 1 hour before breakfast with a full glass of water, and staff interviews confirmed the expectation that Synthroid (Levothyroxine) should be given early in the morning on an empty stomach to ensure optimal absorption, but this was not followed in the observed administration. The administrator stated that nurses are expected to relay pharmacy recommendations to the physician and follow physician instructions and orders, and another nurse confirmed that Synthroid is normally given at 6 AM before breakfast on an empty stomach to increase effectiveness, indicating that the observed practice for this resident deviated from both the physician’s time-sensitive order and the manufacturer’s administration guidelines.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.