Failure to Act on Pharmacist's Recommendation for Digoxin Level Monitoring
Penalty
Summary
The facility failed to ensure that consulting pharmacist recommendations for laboratory monitoring of a resident receiving digoxin were acted upon and addressed in a timely manner. A resident with moderate cognitive impairment, heart failure, and schizophrenia was prescribed digoxin for chronic diastolic heart failure, with daily administration documented and pulse checks recorded. The resident's care plan included general interventions for cardiac complications but did not specify how or when digoxin levels should be monitored. The consulting pharmacist identified the absence of a digoxin level in the medical record and recommended obtaining a digoxin level and basic metabolic panel. Although the physician indicated acceptance of the recommendations, there was no documentation that the digoxin level was obtained or that a rationale was provided for not doing so. Subsequent medication regimen reviews by the consulting pharmacist did not identify further irregularities, but the medical record continued to lack evidence of digoxin level monitoring. Interviews with the DON and consulting pharmacist confirmed that the recommendation for laboratory monitoring was not addressed, and there was no follow-up or documentation explaining the omission. The facility was unable to provide a policy on consulting pharmacist recommendations, and the process for ensuring such recommendations were implemented was not clearly documented or followed.