Failure to Complete Timely Pharmacist Medication Review Leads to Missed Immunosuppressant Doses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a licensed pharmacist performed an Admission Medication Regimen Review (AMRR) for a resident who was readmitted after a hospital stay. The resident, who had a history of heart transplant and was dependent on staff for activities of daily living, required ongoing immunosuppressant therapy with tacrolimus to prevent organ rejection. Upon readmission, the resident's medication orders were changed, and a discrepancy occurred in the transcription and continuation of tacrolimus, resulting in its discontinuation. The facility's policy required medication reconciliation at admission or readmission, including a review of all medications and identification of discrepancies. However, after the resident returned from the hospital, there was no evidence that an AMRR was completed by the consultant pharmacist within the required timeframe. The resident's medical record showed that the tacrolimus order was discontinued on the day of readmission, and no pharmacy review was documented until several days later. As a result, the resident missed 40 doses of tacrolimus over a period of approximately three weeks. Interviews with facility staff and pharmacy management confirmed that AMRRs were not consistently completed during the relevant period, and that the missed review contributed to the failure to identify the medication omission. The error was only discovered after the resident required emergent hospitalization due to missed doses. The facility's own incident report and performance improvement documentation acknowledged the medication was not administered due to incorrect entry in the electronic health record and lack of timely pharmacy review.