Failure to Identify and Act on Medication Irregularities During Monthly Drug Regimen Reviews
Penalty
Summary
The facility failed to ensure that the consultant pharmacist identified and reported medication irregularities during the monthly medication regimen review (MRR) for one resident, and failed to follow up on MRR recommendations for another resident. For one resident with a history of a left femur neck fracture, a physician order was written for cholecalciferol (vitamin D3) at a dose of 2000 mcg daily, which is significantly higher than the manufacturer’s recommended adult dose of 25 mcg/1000 IU daily. This high-dose order was not identified or addressed in the MRRs, and the resident received the excessive dose for over ten months. Both the registered nurse and the director of nursing confirmed that the order should have been for 2000 IU, not 2000 mcg, and acknowledged that the consultant pharmacist did not report or recommend correction of this irregularity during the monthly reviews. Additionally, for another resident who had a long-term order for omeprazole 20 mg daily, the consultant pharmacist documented a recommendation for the physician to evaluate the continued need for the medication due to potential risks associated with prolonged use. However, this recommendation was not presented to the physician, and there was no evidence of physician review or response. The facility’s policy requires that resident-specific MRR recommendations be documented and acted upon, but this process was not followed in this case. These failures resulted in one resident receiving a medication at more than the therapeutic dose for an extended period, and another resident continuing a medication without appropriate physician review of the pharmacist’s recommendation. The facility’s own policies and procedures require thorough MRRs and timely follow-up on pharmacist recommendations, but these were not adhered to in the cases reviewed.