Failure to Administer Ordered Thyroid Medication and Notify Provider
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s order for thyroid medication for one resident. The resident was admitted in December 2024 with diagnoses including polyneuropathy, inflammatory cervical spondylosis, and hypothyroidism. A physician’s order dated 1/4/2025 directed that the resident receive Thyroid Oral 90 mg daily by mouth for hypothyroidism. The January 2025 MAR showed that the thyroid medication was not administered on 1/19, 1/20, 1/22, 1/23, and 1/24, with directions to see nursing notes. Nursing progress notes on 1/19 and 1/20 documented that the thyroid medication was on order, and notes on 1/22 and 1/23 documented that the medication was unavailable. On 1/24, nursing documentation indicated the facility contacted the pharmacy and was informed the thyroid medication was on back-order, with a later note the same day stating the medication was expected to be delivered that night. Review of the clinical record showed no documentation that the provider was notified of the missed doses or that attempts were made to obtain the medication from an alternative source. In interviews, an LPN stated that if a medication was out or on back-order, she would notify the RCM or DNS and they would reach out to the provider for a possible substitute, and the Administrator and DNS stated they would have expected the provider to be notified of the medication being unavailable and of the missed doses. The surveyors determined that the facility’s failure to follow the physician’s order for thyroid medication placed residents at risk for unmet medication needs.
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