Failure to Identify and Report Medication Irregularities in Pharmacist Review
Penalty
Summary
The facility failed to ensure that the consultant pharmacist identified medication irregularities related to the use of Sinemet for a resident during the monthly medication regimen review. The resident, who had a complex medical history including urinary tract infection, type 2 diabetes, atrial fibrillation, iron deficiency anemia, unspecified dementia, hypothyroidism, bipolar disorder, acute embolism and thrombosis, and hypotension, was prescribed Sinemet for Parkinson's disease. However, the resident's Minimum Data Set (MDS) did not reflect a diagnosis of Parkinson's disease, and the medication administration records showed periods where Sinemet was both discontinued and restarted. Observations revealed that the resident exhibited noticeable tremors, and interviews with nursing staff indicated uncertainty about the accuracy of the resident's documented diagnoses. The neurologist's consultation noted that the findings were atypical for idiopathic Parkinson's disease and that a trial of Levodopa (Sinemet) was initiated, with instructions to monitor for adverse reactions. Despite this, there was no evidence that the pharmacist identified or reported any irregularities or made recommendations regarding the use or monitoring of Sinemet during the medication regimen reviews from January to April. The pharmacist also stated there were no concerns and that no adverse effects had been reported by staff. A review of facility policy confirmed that the consultant pharmacist is responsible for thoroughly reviewing each resident's medical record to identify and report medication-related problems, including inadequate monitoring or use of medications without proper indication. In this case, the lack of identification and reporting of irregularities related to Sinemet use constituted a deficiency, as the pharmacist did not follow established guidelines for medication regimen review and irregularity reporting.