Consultant Pharmacist Fails to Identify and Report Medication Errors
Summary
The Consultant Pharmacist (CP) failed to identify and report medications administered outside of physician-ordered parameters for several residents, placing them at risk for adverse side effects and unnecessary medications. For Resident 15, the CP did not report that midodrine was administered 29 times when the resident's blood pressure was above the ordered parameters. Despite the pharmacist's recommendation to obtain hold parameters for another medication, there was no mention of the errors related to midodrine administration. This oversight was confirmed by the administrative nurse and a certified medication aide who admitted to not understanding the symbols indicating when to hold the medication. For Resident 31, the CP did not identify that staff failed to obtain blood pressure readings before administering lisinopril, a medication for hypertension, 78 times. The administrative nurse verified this oversight and expressed confusion as to why the pharmacist had not identified the issue. The facility's policy required the CP to perform a thorough medication regimen review to prevent and resolve medication-related problems, but this was not adhered to in this case. Resident 6 also experienced similar issues, with blood pressure medications and insulin being administered multiple times when the physician's orders indicated they should be held. The CP's monthly reviews did not note these discrepancies, and the administrative nurse confirmed the oversight. Additionally, Resident 4 was given Seroquel for an inappropriate indication (Alzheimer's), and the CP failed to recommend an appropriate indication for its continued use. The administrative nurse verified that the pharmacist had sent monthly reviews but did not address the inappropriate use of Seroquel.
Penalty
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The facility did not ensure that physicians acknowledged and addressed consultant pharmacist recommendations for medication regimen reviews for two residents. Clinical records showed that the pharmacist made multiple recommendations regarding these residents’ medications, but there was no documentation of the specific recommendations or any physician response or action. The DON confirmed that there was no evidence in the medical records that the physicians had addressed the pharmacist’s medication review findings, resulting in noncompliance with state management and nursing services requirements.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with multiple comorbidities, including HTN, AFib, and CKD, received metoprolol 12.5 mg BID despite repeated low BP readings documented on the MAR. An LN confirmed administering the medication on days with low systolic BP and acknowledged that no specific hold parameters had been obtained from the physician. The DON stated that facility practice was to hold BP meds for HTN when systolic BP was below 110, yet review of the MAR showed metoprolol was given multiple times below this threshold. The resident had no care plan addressing HTN or metoprolol use, including monitoring for adverse effects or its BBW, and the consultant pharmacist’s MRR did not identify or recommend action regarding the missing parameters or low BP readings, preceding a change in condition and hospitalization for very low BP.
Surveyors found that the facility did not ensure required monthly medication regimen reviews were consistently documented and that physician responses to pharmacist recommendations were obtained. For one resident with dementia, diabetes, hypertension, and chronic kidney disease who was receiving PRN oxycodone for severe pain, there was no documented monthly medication review for a specific month despite facility policy requiring monthly pharmacist review. For another resident with COPD, dementia with mood disturbance, depression, and multiple psychotropic and related medications, the consultant pharmacist documented concerns about psychotropic polypharmacy and recommended a psychiatric consult and consideration of gradual dose reductions, but the record contained no documented physician or prescriber response. The RN/Clinical Nurse Manager described a process for routing MRRs to physicians but could not locate a response for this resident’s review or explain how missed MRRs were prevented.
A resident’s monthly Medication Regimen Reviews (MRRs) were not timely addressed by providers, and pharmacist recommendations were not acted upon as required by facility policy. The ADON reported that the pharmacist emails MRRs, which are printed and given to an NP to review and mark agree/disagree/other, with changes then entered into the EMR by the NP or unit managers before the next month’s review. For this resident, one MRR contained a recommendation to discontinue melatonin that was not signed and agreed to by the provider until nearly two months later, and the subsequent MRR repeated the same recommendation but had no provider signature, date, or response documented. The ADON acknowledged both MRRs were missed.
A resident receiving hydroxyzine 25 mg for pruritus continued to be administered the medication three times daily because a physician-approved change to twice-daily dosing, recommended in the Consultant Pharmacist’s monthly medication regimen review, was not entered into the EMR. The DON, who received the pharmacist’s emailed report and described a process for obtaining physician signatures and updating orders, did not promptly act on the December review, resulting in ongoing administration of the higher-frequency dose until the pharmacist later alerted her that the change had not been implemented.
Failure to Ensure Physician Response to Pharmacist Medication Review Recommendations
Penalty
Summary
The facility failed to ensure that physicians acknowledged and addressed consultant pharmacist medication regimen recommendations for two residents, as required by policy and regulation. For Resident 6, clinical record review showed that the consultant pharmacist made recommendations regarding the medication regimen on March 20, 2026, but there was no documented evidence of the specific recommendation or that the attending physician had acknowledged or acted upon it. For Resident 12, clinical record review showed that the consultant pharmacist made recommendations regarding the medication regimen on October 20, 2025, and again on February 26, 2026, with no documented evidence of the recommendations or any physician acknowledgment or follow-up action. In an interview on April 17, 2026, at 10:22 a.m., the Director of Nursing confirmed that there was no documented evidence that the medication review recommendations made by the consultant pharmacist for Residents 6 and 12 were addressed by the physician, resulting in noncompliance with state management and nursing services regulations.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Safely Monitor and Administer Antihypertensive Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate monitoring and safe administration of metoprolol for a resident treated for hypertension. The resident was admitted with multiple diagnoses including diabetes mellitus, anemia, atrial fibrillation, acute respiratory failure with hypoxia, and chronic kidney disease. Progress notes documented that on one day the resident had a blood pressure of 100/58, appeared deeply asleep, refused medications and food at lunchtime, and then went back to sleep. The following day, progress notes documented a blood pressure of 86/58, lethargy, slow response, pallor, and that the resident was not responding per baseline, leading to physician contact and transfer to the emergency room. Review of the Medication Administration Record (MAR) showed that the resident had a physician order for metoprolol tartrate 12.5 mg by mouth twice daily for hypertension. The MAR documented multiple low blood pressure readings in January and February, including systolic readings at or near 100 mmHg, on days when metoprolol was administered. A licensed nurse confirmed that she administered metoprolol on days when low blood pressure readings were recorded and acknowledged that when blood pressure medication orders do not include parameters, the nurse should assess the resident, review blood pressure readings, notify the physician, and request clarification for safe parameters. She further stated that if metoprolol had included parameters for holding the medication, the recent change in the resident’s condition that resulted in hospitalization due to very low blood pressure might have been avoided. The DON stated that the facility’s process for administering blood pressure medications included holding parameters based on diagnosis: for residents treated for hypertension, nurses should hold blood pressure medication if systolic blood pressure is less than 110, and for residents treated for heart failure, if systolic blood pressure is less than 100. The DON’s review of the MAR confirmed that metoprolol was administered multiple times when the resident’s systolic blood pressure was below 110, which was not consistent with the facility’s stated process. The DON also confirmed that the resident did not have a care plan addressing hypertension or the use of metoprolol, including monitoring for potential adverse effects and its black box warning. Additionally, the February Medication Regimen Review completed by the consultant pharmacist included the resident but did not contain any recommendations regarding the lack of medication parameters or the documented low blood pressure readings.
Failure to Complete Monthly Medication Reviews and Obtain Physician Response to Pharmacist Recommendations
Penalty
Summary
The deficiency involves the facility’s failure to ensure that the consultant pharmacist completed and documented a monthly medication regimen review (MRR) for one resident and the failure of a physician or prescriber to respond to the pharmacist’s recommendations for another resident. Facility policy titled “Medication Review,” reviewed on 02/11/2026, required the consultant pharmacist to review each resident’s medication regimen monthly. One resident, admitted with diagnoses including Diabetes Mellitus, Dementia, Hypertension, and Chronic Kidney Disease, had an order for oxycodone 5 mg every six hours as needed for severe pain and an admission MDS showing a BIMS score of 03, indicating severe cognitive impairment. Review of this resident’s medical record from September 2025 through February 2026 showed no documented evidence of a monthly medication review for October 2025. During a telephone interview, the consultant pharmacist acknowledged that she should have made a note for every resident every month, confirmed that no note was present in the electronic health record for October, and stated it may have been an error on her part. For another resident, admitted with diagnoses including COPD, dementia with mood disturbance, Type 2 Diabetes Mellitus, depression, and generalized muscle weakness, the medical record contained multiple psychopharmacologic and related medications, including donepezil, trazodone, diazepam (in two different doses and schedules), Fetzima, Abilify, and Remeron. A Medication Regimen Review dated 12/08/2025 documented the pharmacist’s recommendation for a regular psychiatric consult to monitor therapy efficacy and side effects and to consider gradual dose reductions due to polypharmacy of psychopharmacological medications. The clinical record lacked documented evidence of any physician or prescriber response to this recommendation. In an interview, the RN/Clinical Nurse Manager described the process for handling MRR recommendations—receiving them by email, printing and flagging them in the paper chart for physician response, and then filing them in a binder—but was unable to locate the physician’s response to the 12/08/2025 MRR and did not explain how she ensured that no residents’ MRRs were missed.
Failure to Timely Address Pharmacist Medication Regimen Review Recommendations
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely completion and follow-up of monthly Medication Regimen Reviews (MRRs) by a provider, and failure to respond to consulting pharmacist recommendations as required by facility policy. For one resident reviewed for unnecessary medications, the medical record showed MRR entries for two consecutive months documented only as “See [pharmacist’s] report,” without the actual reports initially available. The ADON described the facility’s MRR process, stating that the pharmacist emails the MRRs, she prints the recommendations, and then gives them to the NP to address, with the expectation that the provider will check agree/disagree/other, sign, and date the form. She further stated that some recommendations are implemented in the EMR by the NP, while others are passed to unit managers to enter, and that MRRs are to be completed before the next month’s review. When the surveyor requested the resident’s MRRs, the 1/8 MRR was not provided until the following day, and the 2/9 MRR was initially unavailable. Review of the 1/8 MRR showed a pharmacist recommendation to discontinue melatonin, with the provider marking “agree” and signing on 3/3, nearly two months after the recommendation. The 2/9 MRR, when later produced, contained the same recommendation to discontinue melatonin, but had no provider signature, date, or box checked, and the ADON acknowledged that both MRRs had been missed, noting she had been on vacation. The facility’s policy states that MRR irregularities must be reported to the attending physician, medical director, and DON, must be acted upon, and that non-urgent recommendations must be addressed and documented prior to the next scheduled review, which did not occur in this case.
Failure to Implement Pharmacist-Recommended Change in Hydroxyzine Dosing
Penalty
Summary
The deficiency involves the facility’s failure to act on a Consultant Pharmacist’s monthly medication regimen review and update a resident’s hydroxyzine order in the electronic medical record after the physician had signed to change the order. Resident #8, admitted with diagnoses including pruritus, had a physician’s order dated 7/10/23 for hydroxyzine 25 mg three times a day for pruritus. The Consultant Pharmacist’s Medication Regimen Review dated 1/12/26 documented that on 12/12/25 the physician signed the pharmacy consult report to change the hydroxyzine to 25 mg every morning and midday and discontinue the three-times-daily dosing. However, this new order was not entered into the electronic medical record. Review of the Medication Administration Record from 12/12/25 through 1/18/26 showed that Resident #8 continued to receive hydroxyzine 25 mg three times a day, as evidenced by nursing signatures, indicating the original order remained in effect despite the physician-approved change. The Director of Nursing reported that the Consultant Pharmacist emailed monthly medication regimen reviews and described a process in which physician recommendations from these reviews were to be placed in a physician’s notebook and, once signed, entered into the electronic record. The DON stated she was new to the facility in December 2025 and did not promptly address the December pharmacy reports, resulting in a delay in implementing the reduced hydroxyzine dosing until the Consultant Pharmacist notified her the following month that the frequency had not been changed. The Clinical Compliance Administrator confirmed that medication regimen reviews were expected to be addressed as soon as the DON received them.
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