Pharmacist Failed to Identify and Report Inadequate Medication Indications
Penalty
Summary
The facility failed to ensure that its consultant pharmacist properly identified and reported the absence or inadequacy of indications for use of certain medications during the monthly drug regimen review, as required by facility policy. Specifically, for two residents, the pharmacist did not note irregularities in the use of apixaban and benztropine mesylate. One resident had an order for apixaban with the stated indication of tachycardia, but the medical record did not contain a diagnosis of tachycardia, and the resident's pulse rates were within normal limits. The Assistant Director of Nursing and the pharmacist both confirmed that apixaban is not used to treat tachycardia. Another resident had an order for benztropine mesylate with an unclear indication listed as "other symbolic functions." The pharmacist was unable to clarify what this diagnosis referred to and did not report any irregularities in the medication regimen review. The facility's consultant pharmacy services agreement requires the pharmacist to review each resident's medication regimen monthly, including ensuring that medications are prescribed for appropriate indications, but this process was not followed for the residents in question.