Health inspection·November 21, 2024

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the pharmacist's Medication Regimen Review (MRR) failed to identify the transcription omission of a resident's thyroid medication for her hypothyroidism diagnosis at the time of her readmission. This applies to 1 of 3 (R1) residents reviewed for pharmacy services. The finding includes: R1's EMR (Electronic Medical Record) showed R1 was discharged from the facility on 8/16/2024 and readmitted on [DATE] after she had an ER (Emergency Room) visit. R1's admission Record sheet showed R1 had an active diagnosis of hypothyroidism identified on 6/17/2024. On 11/15/2024 at 10:45 AM, R1 was interviewed regarding her medications. During the interview, R1 had difficulty expressing her thoughts and became frustrated at times. R1 said she felt confused, and tired and had trouble seeing close objects like her call light. R1 said she was worried because her community physician (V25) informed her she had not been receiving her thyroid medication and now her levels were too high. R1 said she was not sure why her thyroid medication had been missed because she had been taking it for a long time. R1's ER visit documents dated 8/19/2024 showed R1 was discharged back to the facility with the facility's Transfer/Discharge Report dated 8/16/2024. The report included R1's active medications, including Levothyroxine Sodium Tablet 150 MCG. Directions: Give 1 tablet by mouth in the morning for low thyroid hormone. R1's hospital documents were uploaded in her EMR on 8/19/2024. V25's (Physician) 11/8/2024 Physician Report showed R1's elevated TSH (thyroid-stimulating hormone) level of 120 was evaluated. The report said She is on half the dose that I had her listed on my medication list. She is feeling tired fatigue confused and is having some ocular issues and I think a lot of the symptoms could be related to her thyroid. The report showed V25 restarted R1's prior dose of Levothyroxine on 11/8/2024, 79 days later. On 11/19/2024 at 1:00 PM, V19 (Pharmacist Manager Consultant) said Pharmacists performed Medication Regimen Reviews (MRRs) for new admissions and readmissions, and then monthly to review the most recent hospital discharge medication lists and current electronic medical records. V19 said MRRs are done to try to catch medication errors and irregularities. V19 said he reviewed R1's MRRs dated 8/21/2024 when she readmitted , and then performed the following monthly MRRs dated 9/5/2024 and 9/22/2024, and R1's hospital discharge documents dated 8/19/2024. V19 confirmed R1's Levothyroxine medication Page 1 of 4 145699 145699 11/21/2024 Avantara of Elgin 1950 Larkin Avenue Elgin, IL 60123

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was missed when she was readmitted on [DATE] and it was omitted from her medication list. V19 said it was unfortunate that R1's thyroid medication irregularity was also missed again during her MRR on 8/21/2024 and the following months. V19 said he was not sure if her hospital documents with her most recent medication list were reviewed by the pharamcists. R1's Pharmacist-Medication Regimen Review report dated 8/21/2024 said R1's Medication Review Results showed No irregularities. R1's Pharmacist-Medication Regimen Review report dated 9/5/2024 continued to show no irregularities were identified regarding R1's missing thyroid medication. R1's Pharmacist-Medication Regimen Review report dated 9/22/2024 said R1's Medication Review Results showed No irregularities. The facility's policy titled Medication Regimen Review dated 8/16/2024 said The Consultant Pharmacist shall provide pharmaceutical care consultation including the medication regimen review at least once a month for each resident residing in certified areas of a skilled long term care facility .Federally mandated standards of care as well as other applicable standards serve as the basis for review to ensure that resident's medications are promoting or maintain the resident's highest level of function in congruence with the resident's therapeutic goals and to identify clinically significant risks and/or adverse medication reactions . 145699 Page 2 of 4 145699 11/21/2024 Avantara of Elgin 1950 Larkin Avenue Elgin, IL 60123

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to transcribe a resident's medications as ordered, resulting in the original does of thyroid medication not being administered for 79 days. Residents Affected - Few This applies to 1 of 5 (R1) residents reviewed for medications. The finding includes: R1's EMR (Electronic Medical Record) showed R1 was discharged from the facility on 8/16/2024 and readmitted on [DATE] after she had an ER (Emergency Room) visit. R1's admission Record sheet showed R1 had an active diagnosis of hypothyroidism identified on 6/17/2024. On 11/15/2024 at 10:45 AM, R1 was interviewed regarding her medications. During the interview, R1 had difficulty expressing her thoughts and became frustrated at times. R1 said she felt confused, and tired, and she was having trouble seeing close objects like her call light. R1 said she was worried because her Community Physician (V25) informed her she had not been receiving her thyroid medication and now her levels were too high. R1 said she was not sure why her thyroid medication had been missed because she had been taking it for a long time. R1's ER visit documents dated 8/19/2024 showed R1 was discharged back to the facility with the facility's original Transfer/Discharge Report from 8/16/2024. The report showed R1's active medications, including Levothyroxine Sodium Tablet 150 MCG. Directions: Give 1 tablet by mouth in the morning for low thyroid hormone. R1's hospital documents were uploaded in her EMR on 8/19/2024. R1's lab results dated 11/4/2024 showed R1's TSH (thyroid-stimulating hormone) level was 120.542 H (high). (TSH reference value range is 0.550-4.780 uIU/mL.) R1's physician visit report from V25 (Physician) dated 11/8/2024 showed R1's elevated TSH (thyroid-stimulating hormone) level of 120 was evaluated. The report said She is on half the dose that I had her listed on my medication list. She is feeling tired fatigue confused and is having some ocular issues and I think a lot of the symptoms could be related to her thyroid. The report showed V25 restarted R1's prior dose of Levothyroxine. On 11/15/2024 at 2:55 PM, V2 (Director of Nursing/DON) said R1's in-house Physician (V11) had ordered routine labs, including a TSH level, on 11/4/2024, and then started R1 on Levothyroxine medication for her thyroid because it was extremely elevated. V2 said then R1's daughter informed him that V25 (R1's Community Physician) reviewed her medications and informed them that R1's thyroid medication was omitted when she was readmitted , and that R1 was restarted at a lower dose. V2 said he expected nursing staff to review the most current medication list at the time of admission, and readmission, and to clarify any discrepencies with the Physician to ensure medication safety. R1 said he was unsure why R1's Levothyroxine was not reordered when she was readmitted and continued to be missed. R1's care plan had a focus problem for R1's diagnosis of hypothyroidism initiated on 9/19/2024. The care plan's goals included [R1's] Thyroid function tests will be within normal limits .will be compliant with thyroid replacement therapy . R1's EMAR (Electronic Medication Record) for August 2024 showed R1 last received Levothyroxine Sodium (thyroid hormone medication) 150 mcg (micrograms) on 8/16/2024, prior to her discharge. R1's EMAR did not show R1's Levothyroxine being restarted when she was readmitted on [DATE]. 145699 Page 3 of 4 145699 11/21/2024 Avantara of Elgin 1950 Larkin Avenue Elgin, IL 60123

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R1's EMAR for September 2024 showed R1's original Levothyroxine Sodium dosage was not restarted. R1's EMAR for October 2024 showed R1's Levothyroxine Sodium was still not restarted. R1's EMAR for November 2024 showed R1 was started on Levothyroxine Sodium 75 mcg on 11/6/2024 and then increased to 150 mcg on 11/9/2024. R1's lab results dated 11/11/2024 showed R1's TSH level was 104.958 H. The facility's policy titled admission and readmission Policy dated 7/12/2024 said, It is the policy of this facility to ensure that the facility complies with federal regulations in terms of admission and readmission of resident. Procedures: 2) Verify orders from the hospital with physician or on-call physician. 3) Obtain physician orders based on resident needs. 4) Carry out physician orders. The facility's policy titled Physician Orders dated 8/16/2024 said, The facility shall ensure to follow physician orders as it is written in the POS. 1. Upon admission and readmission, the facility will verify transfer orders from the hospital with the resident's attending physician or physician on call .The nurse may question and clarify physician orders that are not clear and are questionable . 145699 Page 4 of 4