Arnold Walter Nursing & Rehabilitation Center

The surveyor then reviewed the medication administration record with the DON which showed that Resident #2 did not receive Liothyronine on 1/28/25 at 4:00 PM, 1/28/25 at 8:00 PM, 1/29/25 at 5:00 AM.

Comment: Awaiting pharmacy delivery.

There was no documentation that the physician was informed of the omission. On 2/1/25 and 2/2/25 Resident #2 did not receive Liothyronine as ordered at 8:00 PM, and there was no comment regarding the omission.

The surveyor then asked the DON if Resident #2 should have received the Liothyronine as ordered, the DON stated that there should be a rationale added if the medication was not administered.

The surveyor then asked the DON what her expectations regarding medications administration/ omission of medication was.

The DON stated the physician, and the Unit manager were to be notified, the staff should have followed up with the pharmacy for a stat delivery or an alternative.A review of the facility provided policy titled, Policies, Procedures and Information last revised 12/27/24 included the following: POLICYIt is the policy of this facility to ensure that Medication Administration and Documentation occurs in a timely and accurate manner.The Electronic Medication Administration Record (EMAR) is the form onto which all medication orders are transcribed from physician electronic orders, from which medications are poured and administered and on which medication doses are documented.

Under procedure the following were documented:Immediately notifies nursing supervisor if medication is unavailable for administration and notifies Physician/NP of the same.

Contacts pharmacy to obtain medications.Documents administration of medication in the EMAR immediately following administration.

Notes in the EMAR medications not administered (i.e. refused, etc.) and identifies reason. NJAC 8:39-29.2 (d)

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