HospitalInspections.org

Based on record review and interview the hospital failed to provide care in a safe environment for one of one patient (Patient #1) in that the patient did not receive medication to treat her diagnosed hypothyroid condition until 14 days after the medication was ordered by the physician.

Findings included:

Emergency Department Triage Report dated 03/10/14 at 19:32 reflected Patient #1 was admitted for Bowel Obstruction.

Home Medication Reconciliation Order Form dated 03/11/14 at 03:15 reflected medications taken by the patient prior to admission included Synthroid 15 mcg daily for "thyroid."

The Physician Orders and Progress Notes dated 03/12/14 at 06:30 reflected diagnoses included Hypothyroidism.

Manually written Physician Orders dated 03/19/14 at 10:30 reflected an order for Synthroid 15 microgram (mcg) daily per nasogastric tube. There is no evidence in the medical record that Patient #1 received the medication.

Computerized Physician Order Entry (CPOE) dated 04/02/14 at 13:14 reflected an order for a thyroid physician consult and to administer Synthroid 25 mcg per feeding tube daily.

A consult for the chief complaint of hypothyroidism was dated and signed on 04/02/14 at 16:35. It reflected a "new problem" of Hypothyroidism. The report noted Patient #1's thyroid profile was "...consistent with hypothyroidism..." Patient #1 "...has not received any levothyroxine [Synthroid] since admission...[and] home medications...include Synthroid but the dose is listed as 15 mcg which is of course not possible..."

CPOE orders dated 04/09/14 at 13:06 reflected Patient #1 took the last dose of Synthroid 150 mcg by mouth on 03/09/14, one day prior to her admission to the hospital.

During an interview on 04/11/14 at 11:25 Hospital Staff #3 stated Patient #1's home medications including Synthroid were stopped on admission because the patient did not take anything by mouth.

Hospital Staff #8 agreed on 04/11/14 at 13:30 that Patient #1 received the first dose of Synthroid 25 mcg on 04/02/14 at 15:49.