Consultant Pharmacist Failed to Identify Need for Lab Monitoring with Antipsychotic Use
Penalty
Summary
The facility's consultant pharmacist failed to identify and address drug-related issues for one resident during the monthly drug regimen review. Specifically, a resident with diagnoses including anxiety disorder, schizoaffective disorder, depression, diabetes mellitus II, and hyperlipidemia was prescribed quetiapine, an antipsychotic medication. The resident's medical record did not include baseline laboratory tests such as glycated hemoglobin (A1C) or a lipid panel, which are recommended for monitoring due to the resident's diagnoses and the known side effects of quetiapine. The consultant pharmacist's medication regimen reviews from January 2025 to the present did not include any recommendations for these necessary lab tests. During an interview and record review, the DON confirmed that there were no lab orders or recommendations for a lipid panel or hemoglobin A1C for the resident, despite facility policy and FDA guidelines indicating the need for such monitoring. The facility's policies require monitoring for metabolic side effects, including changes in cholesterol, triglycerides, and blood sugar, and specify that the consultant pharmacist should review laboratory results as part of the medication regimen review. This omission was identified through observation, interview, and record review, and was found to have the potential for unsafe medication use for all residents in the facility.